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Background The growing societal and economic impact of Alzheimer’s disease (AD) is further compounded by the present lack of disease-modifying interventions. Non-pharmacological intervention approaches, such as exercise, have the potential to be powerful approaches to improve or mitigate the symptoms of AD without added side effects or financial burden associated with drug therapies. Various forms and regiments of exercise (i.e., strength, aerobic, multicomponent) have been reported in the literature; however, conflicting evidence obscures clear interpretation of the value and impact of exercise as an intervention for older adults with AD. The primary objective of this review will be to evaluate the effects of exercise interventions for older adults with AD. In addition, this review will evaluate the evidence quality and synthesize the exercise training prescriptions for proper clinical practice guidelines and recommendations. Methods This systematic review and meta-analysis will be carried out by an interdisciplinary collective representing clinical and research stakeholders with diverse expertise related to neurodegenerative diseases and rehabilitation medicine. Literature sources will include the following: Embase, PsychINFO, OVID Medline, and Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily. Inclusion criteria are participants with late onset AD and structured exercise interventions with prescribed duration, frequency, and intensity. The primary outcome of this study will center on improved or sustained cognitive functioning. Secondary outcomes will include institutionalization-related outcomes, ability in activities of daily living, mood and emotional well-being, quality of life, morbidity, and mortality. Analysis procedures to include measurement of bias, data synthesis, sensitivity analysis, and assessment of heterogeneity are described in this protocol. Discussion This review is anticipated to yield clinically meaningful insight on the specific value of exercise for older adults with AD. Improved understanding of diverse exercise intervention approaches and their specific impact on various health- and function-related outcomes is expected to guide clinicians to more frequently and accurately prescribe meaningful interventions for those affected by AD. Systematic review registration PROSPERO CRD42020175016.

Objective To conduct a scoping review on classifications of mild stroke based on stroke severity assessments and/or clinical signs and symptoms reported in the literature. Data Sources Electronic searches of PubMed, PsycINFO (Ovid), and Cumulative Index to Nursing and Allied Health (CINAHL–EBSCO) databases included keyword combinations of mild stroke, minor stroke, mini stroke, mild cerebrovascular, minor cerebrovascular, transient ischemic attack, or TIA. Study Selection Inclusion criteria were limited to articles published between January 2003 and February 2018. Inclusion criteria included studies (1) with a definition of either mild or minor stroke, (2) written in English, and (3) with participants aged 18 years and older. Animal studies, reviews, dissertations, blogs, editorials, commentaries, case reports, newsletters, drug trials, and presentation abstracts were excluded. Data Extraction Five reviewers independently screened titles and abstracts for inclusion and exclusion criteria. Two reviewers independently screened each full-text article for eligibility. The 5 reviewers checked the quality of the included full-text articles for accuracy. Data were extracted by 2 reviewers and verified by a third reviewer. Data Synthesis Sixty-two studies were included in the final review. Ten unique definitions of mild stroke using stroke severity assessments were discovered, and 10 different cutoff points were used. The National Institutes of Health Stroke Scale was the most widely used measure to classify stroke severity. Synthesis also revealed variations in classification of mild stroke across publication years, time since stroke, settings, and medical factors including imaging, medical indicators, and clinical signs and symptoms. Conclusions Inconsistencies in the classification of mild stroke are evident with varying use of stroke severity assessments, measurement cutoff scores, imaging tools, and clinical or functional outcomes. Continued work is necessary to develop a consensus definition of mild stroke, which directly affects treatment receipt, referral for services, and health service delivery.

Using a Survey to Characterize Rehabilitation Professionals' Perceptions and Use of Complementary, Integrative, and Alternative Medicine

Persons with mild stroke experience motor and cognitive impairments that negatively affect their health and quality of life. To address these deficits, it is essential for clinicians and researchers to precisely identify mild stroke survivors. Despite the fact that half of all strokes are categorized as mild, no standards exist on what constitutes a "mild" stroke. The purpose of this study is to summarize the current classification of mild stroke using a mapping review approach. Strategies to categorize "mild stroke" severity were explored in 188 papers indexed in the PubMed database. The results indicate that there was substantial variability in the procedures and scoring criteria used to determine mild stroke. To identify persons with mild stroke, researchers have largely applied assessment instruments developed to inform acute stroke care (eg, National Institutes of Health Stroke Scale, Modified Rankin Scale, Barthel Index). Unfortunately, these approaches demonstrate floor effects and fail to detect the long-term disabling impairments that often limit the outcomes of mild stroke survivors. Additional research is warranted to suggest an evidence-based mild stroke categorization strategy that enhances diagnosis, treatment, and referral decisions to the benefit of mild stroke survivors.

Background Technological advances have allowed a variety of computerized cognitive training tools to be engineered in ways that are fun and entertaining yet challenging at a level that can maintain motivation and engagement. This revolution has created an opportunity for gerontological scientists to evaluate brain gaming approaches to improve cognitive and everyday function. The purpose of this scoping review is to provide a critical overview of the existing literature on nonimmersive, electronic brain gaming interventions in older adults with mild cognitive impairment or dementia. Research Design and Methods Systematic search was conducted using 7 electronic databases from inception through July 2017. A comprehensive 2-level eligibility process was used to identify studies for inclusion based on PRISMA guidelines. Results Seventeen studies met eligibility criteria. Majority of the studies were randomized controlled trials (n = 13) and incorporated an active control (n = 9). Intervention doses ranged from 4 to 24 weeks in duration with an average of 8.4 (±5.1 standard deviation [SD]) weeks. Session durations ranged from 30 to 100 min with an average of 54 (±25 SD) minutes. Nearly half of studies included a follow-up, ranging from 3 months to 5 years (n = 8). For most studies, brain gaming improved at least one cognitive outcome (n = 12); only one study reported improvement in activities of daily living. Discussion and Implications This scoping review conveys the breadth of an emerging research field, which will help guide future research to develop standards and recommendations for brain gaming interventions which are currently lacking.

Objective The objective of this study was to determine the ability of the Activity Measure for Post-Acute Care “6-Clicks” Basic Mobility Short Form to predict patient discharge destination (home vs postacute care [PAC] facility) from the cardiac intensive care unit (ICU), including patients from the cardiothoracic surgical ICU and coronary care unit. Methods This retrospective cohort study utilized electronic medical records of patients in cardiac ICU (n = 359) in an academic teaching hospital in the southeastern region of United States from September 1, 2017, through August 31, 2018. Results The median interquartile range age of the sample was 68 years (75–60), 55% were men, the median interquartile range 6-Clicks score was 16 (20–12) at the physical therapist evaluation, and 79% of the patients were discharged to home. Higher score on 6-Clicks indicates improved function. A prediction model was constructed based on a machine learning approach using a classification tree. The classification tree was constructed and evaluated by dividing the sample into a train-test split using the Leave-One-Out cross-validation approach. The classification tree split the data into 4 distinct groups along with their predicted outcomes. Patients with a 6-Clicks score >15.5 and a score between 11.5 and 15.5 with primary insurance other than Medicare were discharged to home. Patients with a 6-Clicks score between 11.5 and 15.5 with Medicare insurance and those with a score ≤11.5 were discharged to a PAC facility. Conclusion Patients with lower 6-Clicks scores were more likely to be discharged to a PAC facility. Patients without Medicare insurance had to be significantly lower functioning, as indicated by lower 6-Clicks scores for PAC facility placement than those with Medicare insurance. Impact The ability of 6-Clicks along with primary insurance to determine discharge destination allows for early discharge planning from cardiac ICUs.

Differences exist across breast cancer screening guidelines regarding frequency of screening and age of discontinuation for older women (≥70 years) at average risk for breast cancer. These differences highlight concerns about the benefits and harms of screening, and may negatively impact older women’s ability to make informed screening decisions. This study examined preferences for communicating about screening mammography among racially/ethnically diverse, older women. In-depth interviews were conducted with 59 women with no breast cancer history. Non-proportional quota sampling ensured roughly equal numbers on age (70–74 years, ≥75 years), race/ethnicity (non-Hispanic/Latina White, non-Hispanic/Latina Black, Hispanic/Latina), and education (≤high school diploma, >high school diploma). Interviews were audio-recorded, transcribed, and analyzed using NVivo 10. Thematic analyses revealed that rather than being told to get mammograms, participants wanted to hear about the benefits and harms of screening mammography, including overdiagnosis. Participants recommended that this information be communicated via physicians or other healthcare providers, included in brochures/pamphlets, and presented outside of clinical settings (e.g., in senior groups). Results were consistent regardless of participants’ age, race/ethnicity, or education. Findings revealed that older women desire information about the benefits and harms of screening mammography, and would prefer to learn this information through discussions with healthcare providers and multiple other formats.

Caregivers usually are not involved while planning the stroke survivor's medical and rehabilitation goals and interventions. This review aimed to identify the needs of stroke survivors as perceived by their caregivers.A literature search from 2003 to 2014 was conducted using Medline, CINAHL, PsychINFO, and Google Scholar. Sixty-six studies were included. Most studies excluded did not encompass caregivers' perspectives. Four reviewers screened the titles, abstracts, and full texts of the articles for inclusion. The data extracted from these studies were synthetized into metathemes.Fifty-two qualitative, ten quantitative survey, and four mixed-methods studies were included in the final synthesis. The studies came from 11 countries. The data synthesis produced following three metathemes: (a) body functional needs, including psychological function, physical function, cognitive function, and uncertainty related to function; (b) activity and participatory needs, including healthy lifestyle, physical activities, speech, independence, cognitive activities, and uncertainty related to activities and participation; and (c) environmental needs, encompassing support, services, safety, accommodation and accessibility, and uncertainty related to environmental factors.This scoping review identified a range of needs of stroke survivors as perceived by their caregivers. Incorporating the caregiver's preferences and values into clinical decisions may improve outcomes among stroke survivors.

To explore the mobility-related preferences among stroke survivors and caregivers following post-acute rehabilitation at inpatient or skilled nursing facilities.In this cross-sectional study; semi-structured, qualitative interviews of stroke survivors (n = 24) and informal caregivers (n = 15) were conducted. The participants were recruited from the community.Comparative content analysis was used to identify themes by two independent coders. The survivors (68 years) and caregivers (58 years) mentioned mobility-related consequences including inability to walk, balance, drive, and transfer; and increased falls. The survivors (63%) and caregivers (73%) also mentioned the use of assistive devices. The common rehabilitation activities included: walking (62%); followed by standing and mobility; strength and balance; and wheelchair skills. Some stroke survivors were dissatisfied as their rehabilitation was not patient-centered. Frequently mentioned outcome preferences by survivors were ability to walk (88%), move, and balance. They also wanted to acquire assistive devices to move independently. Caregivers were concerned with the survivor's safety and wanted them to drive (53%), prevent falls, have home accommodations, and transfer independently. Caregivers (40%) also expressed the importance of receiving realistic information.This study suggests a need to consider the stroke survivors' and caregivers' mobility outcome preferences to improve the patient-centered rehabilitation care. Implications for Rehabilitation Stroke survivors and caregivers tend to differ in their outcome preferences. Caregivers expressed concern for transfers, driving, fall prevention, home modifications, and wished for realistic information. Incorporating stroke survivors and their families' perspectives during rehabilitation may enhance patient-centered outcomes.

Patients and caregivers have not typically been involved in the selection of a post-acute care (PAC) provider. In 2015, the Centers for MedicareMedicaid Services proposed the need to involve patients and their families during discharge planning. Engaging patients in rehabilitation decisions encourages shared decision making among patients and their clinicians. The purpose of this study was to examine stroke survivors' perspectives on their involvement in selecting a PAC provider and their goal setting and their satisfaction with the rehabilitation stay and their discharge advice for stroke survivors, prior to 2015.This qualitative study utilized semistructured interviews. Thematic content analysis was performed on interviews involving 18 stroke survivors (mean age = 68 years) related to their involvement in planning for their inpatient rehabilitation facility or skilled nursing facility stay, goal setting, and discharge needs.More than half the participants were not involved in the selection of their PAC setting and believed that doctors made these decisions. Around two-fifths of stroke survivors reported that they were not involved in rehabilitation goal setting. Most patients were satisfied with their rehabilitation stay. When asked to recommend discharge topics for other stroke survivors, participants recommended additional information on health care services, interventions, and insurance coverage.Despite recommendations to include stroke patients in PAC selection and goal setting, many former inpatient rehabilitation facility and skilled nursing facility patients report not being involved in either aspect of care.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A273).

The purpose of this study was to conduct an overview of systematic reviews (SRs) to appraise the published evidence related to pharmacological interventions after traumatic brain injury (TBI). Searches were conducted with Medline, Embase, PsycINFO, Web of Science, PubMed. 780 retrieved SRs underwent a two-level screening to determine inclusion. Data extracted included participant characteristics, TBI severity, study design, pharmacological interventions, and outcomes. SRs were assessed for methodological quality by using the AMSTAR measurement tool. After removing duplicates, 166/780 SRs published between 1990-2017 were reviewed, 62 of which met inclusion criteria. More than 90 drugs and 22 substance-classes were extracted. Most medications were administered during the acute stage. Mild TBI was included in 3% of the SRs. Physiological outcomes comprised 45% of the SRs, primarily mortality. Activities of daily living (ADLs) outcomes constituted 22% of the SRs followed by cognition (13%) and psychological/behavioral outcomes (13%). Only 7% of the SRs assessed adverse events. Inconsistencies in definitions, methods, and heterogeneity of instruments used to measure treatment response were noted. Only a third of the SRs had high methodological quality. Most SRs had heterogeneous TBI samples, outcomes, or methodologies making it difficult to synthesize findings into recommended guidelines. This study demonstrated a need for adequately powered and rigorous randomized clinical trials (RCTs) to provide generalizable evidence on the effectiveness of pharmacologic interventions for TBI. PROSPERO Registration: CRD42015017355.

The objective of this work was to present comprehensive descriptive summaries of program interruptions and short-stay transfers among Medicare fee-for-service beneficiaries receiving inpatient rehabilitation after stroke, traumatic brain injury (TBI), and traumatic spinal cord injury (SCI).Retrospective cohort study of Medicare beneficiaries with any of the 3 conditions of interest who were admitted to inpatient rehabilitation directly from an acute hospital between July 1, 2012, and November 15, 2013.In the final sample (stroke, n = 71 769; TBI, n = 7109; SCI, n = 659), program interruption rates were 0.9% (stroke), 0.8% (TBI), and 1.4% (SCI). Short-stay transfer rates were 22.3% (stroke), 21.8% (TBI), and 31.6% (SCI); 14.7% of short-stay transfers and 12.3% of interruptions resulting in a return to acute care were identified as potentially preventable among those with stroke; 10.2% of transfers and 11.7% of interruptions among those with TBI, and 3.8% of transfers and 11.1% of interruptions among those with SCI.Broad health care policies aimed at improving quality and reducing costs are currently being implemented. Reducing program interruptions and short-stay transfers during inpatient rehabilitative care represents a potential target for care-improvement efforts. Future research focused on identifying modifiable risk factors for potentially undesirable outcomes will allow for targeted preventative interventions.

Objective To identify changes in concentrations of inflammatory mediators in plasma and urine after traumatic spinal cord injury (SCI) and before the occurrence of a first pressure ulcer. Design Retrospective; secondary analysis of existing data. Setting Acute hospitalization and inpatient rehabilitation sites at a university medical center. Participants Individuals with a pressure ulcer and plasma samples (n=17) and individuals with a pressure ulcer and urine samples (n=15) were matched by age and plasma/urine sample days to individuals with SCI and no pressure ulcer (N=35). Interventions Not applicable. Main Outcome Measures Plasma and urine samples were assayed in patients with SCI, capturing samples within 4 days after the SCI to a week before the formation of the first pressure ulcer. The Wilcoxon signed-rank test was performed to identify changes in the inflammatory mediators between the 2 time points. Results An increase in concentration of the chemokine interferon-γ–induced protein of 10kd/CXCL10 in plasma ( P P =.01) were observed before occurrence of a first pressure ulcer (∼4d) compared with matched controls. Conclusions Altered levels of inflammatory mediators in plasma and urine may be associated with pressure ulcer development after traumatic SCI. These inflammatory mediators should be explored as possible biomarkers for identifying individuals at risk for pressure ulcer formation.

OBJECTIVES: Few studies have explored the lived experiences of chronic cognitive and mood symptoms following stroke using a racially/ethnically diverse sample. Therefore, we aimed to explore the perceptions of chronic post-stroke cognition and mood symptoms and goals among a racially/ethnically diverse sample of community-dwelling adults aging with stroke. METHOD: This qualitative study using mixed-methods analysis included semi-structured interviews regarding perceived post-stroke cognition and mood symptoms among community-dwelling stroke survivors at least one-year post stroke. Transcripts were subjected to thematic content analysis, and differences in theme usage patterns by age, gender, race/ethnicity, and post-acute rehabilitation setting were assessed using an inferential clustering technique. RESULTS: The majority of participants (93%) reported cognition-related themes, including language and communication, memory, thinking abilities, comprehension, visual-spatial processing, and cognitive assessments and training. Nearly half of participants mentioned mood-related themes, including depression, aggression and anger, mood fluctuations, anxiety, and psychological services and medication. Nearly half reported an unmet need for cognition or mood-related treatment. Inferential clustering analysis revealed that older participants reported a different pattern of cognition and mood symptoms than those aged younger than 65 (p=.02). Older adults were more likely to describe post-stroke language/communication changes, while younger adults described post-stroke mood changes. CONCLUSION: Stroke survivors experienced cognitive and mood-related symptoms beyond one-year post stroke, which has implications for long-term assessment and management. Incorporation of continued symptom monitoring into existing community-based services is needed to address chronic cognition and mood symptoms affecting the quality of life of persons with stroke.

Objectives Current research on the perceptions of overdiagnosis or overdetection of breast cancer has largely been conducted outside of the USA and with women younger than 70 years. Therefore, we explored older women’s perceptions about the concept of overdetection of breast cancer and its influence on future screening intentions. Design Mixed-methods analysis using purposive sampling based on race/ethnicity, age and educational level. Semistructured interviews, including two hypothetical scenarios illustrating benefits and harms of screening and overdetection, were analysed using inductive and deductive thematic approaches. An inferential clustering technique was used to assess overall patterns in narrative content by sociodemographic characteristics, personal screening preferences or understanding of overdetection. Setting Houston/Galveston, Texas, USA. Participants 59 English-speaking women aged 70 years and older with no prior history of breast cancer. Results Very few women were familiar with the concept of overdetection and overtreatment. After the scenarios were presented, half of the women still demonstrated a lack of understanding of the concept of overdetection. Many women expressed suspicion of the concept, equating it to rationing. Women who showed understanding of overdetection were more likely to express an intent to discontinue screening, although 86% of the women stated that hearing about overdetection did not influence their screening decision. Themes identified did not differ by race/ethnicity, education, age or screening preferences. Differences were identified between women who understood overdetection and women who did not (r=0.23, p Conclusions Many older women did not understand the concept of overdetection, in addition to being suspicious of or resistant to the concept. Providing older women with descriptions of overdetection may not be sufficient to influence screening intentions.

Introduction Older Mexican Americans are living longer with multiple chronic conditions (MCCs). This has placed greater demands on caregivers to assist with basic activities of daily living (ADL) or instrumental activities of daily living (IADL). To understand the needs of older Mexican-American care recipients, we examined the impact of MCC on ADL and IADL limitations. Methods We analyzed data from 485 Mexican American care-receiving/caregiving dyads. Selected MCCs in the analysis were diabetes, hypertension, stroke, heart disease, arthritis, emphysema/chronic obstructive pulmonary disease, cognitive impairment, depression, and cancer. Care recipients were dichotomized as having 3 or more conditions or as having 2 or fewer conditions. Three comorbidity clusters were established on the basis of the most prevalent health conditions among participants with comorbid arthritis and hypertension. These clusters included arthritis and hypertension plus: diabetes (cluster 1), cognitive impairment (cluster 2), and heart disease (cluster 3). Results Care recipients with 3 or more chronic conditions (n = 314) had higher odds of having mobility limitations (OR = 1.98; 95% CI, 1.34-2.94), self-care limitations (OR = 2.53; 95% CI, 1.70-3.81), >3 ADL limitations (OR = 2.00; 95% CI, 1.28-3.17), and >3 IADL limitations (OR = 1.88; 95% CI, 1.26-2.81). All clusters had increased odds of ADL and severe ADL limitations. Of care recipients in cluster 2, those with arthritis, hypertension, and cognitive impairment had significantly higher odds of mobility limitations (OR = 2.33; 95% CI, 1.05-5.24) than those with just arthritis and hypertension. Conclusion MCCs were associated with more ADL and IADL limitations among care recipients, especially for those with hypertension and arthritis plus diabetes, cognitive impairment, or heart disease. These findings can assist in developing programs to meet the needs of older Mexican-American care recipients.

Objective Screening mammography is associated with reduced breast cancer-specific mortality; however, among older women, evidence suggests that the potential harms of screening may outweigh the benefits. We used a qualitative approach to examine the willingness of older women from different racial/ethnic groups to discontinue breast cancer screening. Methods Women ≥70 years of age who reported having a screening mammogram in the past 3 years and/or reported that they intended to continue screening in the future were recruited for in-depth interviews. Participants who intended to continue screening were asked to describe how the following hypothetical scenarios would impact a decision to discontinue screening: health concerns or limited life expectancy, a physician's recommendation to discontinue, reluctance to undergo treatment, and recommendations from experts or governmental panels to stop screening. Semi-structured, face-to-face interviews were audio-recorded. Data coding and analysis followed inductive and deductive approaches. Results Regardless of the scenario, participants (n = 29) expressed a strong intention to continue screening. Based on the hypothetical physician recommendations, intentions to continue screening appeared to remain strong. They did not envision a change in their health status that would lead them to discontinue screening and were skeptical of expert/government recommendations. There were no differences observed according to age, race/ethnicity, or education. Conclusions Among older women who planned to continue screening, intentions to continue breast cancer screening appear to be highly resilient and resistant to recommendations from physicians or expert/government panels.

Objective. This study explored the experiences and needs of older adults during and following Hurricane Ike. Method. Two focus group interviews were conducted among older adults who lived in or around Galveston Island before Hurricane Ike. Nine older adults (six women and three men) participated in two focus group sessions. These qualitative interviews were audio recorded, transcribed, and analyzed using thematic content analyses. Results. The findings of this study reveal the need for continuity in health care services, medications, psychological support, social and family support, community-level services, and information among older adults. Conclusions. The contribution of factors such as health care continuity and psychological support reinforces the importance of specific postdisaster resources to meet the needs of older adults following hurricanes. These results suggest the importance of designing hurricane preparedness guidelines specifically for older adults.

There is insufficient evidence to determine the benefits and harms of screening mammography for women aged 75 and older. Therefore, guidelines emphasize on shared decision-making. This study aimed to understand older women’s mammography screening decision, physician’s role in their decision, and their willingness to discontinue screening. Using stratified sampling based on age (70–74 vs. 75+), race/ethnicity (Non-Hispanic Blacks, Hispanics, Non-Hispanic Whites) and education (≤high school vs. >high school), fifty-six older women with no breast cancer history participated in semi-structured interviews to discuss their decision-making process and preferences for screening. Iterative, comparative thematic analyses revealed that the majority of the older women desired to continue screening. Women aged 75+ tended to discontinue, whereas those aged 70–74 tended to continue screening. Seventy-seven percent of the older women stated that their physician initiated the discussion regarding continuing/discontinuing screening, whereas 18% initiated the discussion, 1% were influenced by a relative and only 4% stated involvement in shared decision-making, describing the process as a ‘mutual thing between us’ or ‘both [of us].’ Most women followed their physician’s recommendations for screening. Nearly 80% of those continuing mammography had no personal desire to stop, even for those aged 75+ (38%). Some of the reasons why a continuer may discontinue mammography screening were health, physician recommendation, harms, evidence or beyond the age of 80. This study suggests a need for improved communication between physicians and older women regarding the benefits and harms associated with mammography screening.

Secondary analysis of data from a prospective cohort study. The objective of this study was to identify the medical and demographic factors associated with the development of pressure ulcers during acute-care hospitalization and inpatient rehabilitation following acute spinal cord injury. The study was carried out at acute hospitalization, inpatient rehabilitation and outpatient rehabilitation sites at a university medical center in the United States. Adults with acute traumatic spinal cord injury (n=104) were recruited within 24–72 h of admission to the hospital. Pressure ulcer incidence was recorded. Thirty-nine participants out of 104 (37.5%) developed at least one pressure ulcer during acute-care hospitalization and inpatient rehabilitation. Univariate logistic regression analyses revealed significant association of pressure ulcer incidence for those with pneumonia and mechanical ventilation (P=0.01) and higher injury severity (ASIA A) (P=0.01). Multiple logistic regression showed that the odds of formation of a first pressure ulcer in participants with ASIA A was 4.5 times greater than that for participants with ASIA B, CI (1–20.65), P=0.05, and 4.6 times greater than that for participants with ASIA C, CI (1.3–16.63), P=0.01. Among individuals with acute traumatic SCI, those with high-injury severity were at an increased risk to develop pressure ulcers. Pneumonia was noted to be associated with the formation of pressure ulcers.

OBJECTIVE. This study’s objective was to test the psychometrics of Smith’s (2013) Low Vision Independence Measure (LVIM) using the Rasch model. METHOD. A cohort design was used with 93 participants receiving occupational therapy for low vision. Confirmatory factor analysis (CFA) with a parceling approach was used to test the LVIM factors and Rasch analysis to examine item-level psychometrics. RESULTS. Participants’ average age was 78.9 yr (standard deviation = 12.1), and the majority were female (72.8%) with macular degeneration (62.3%). The CFA revealed two measurement factors: visual field or scotoma (n = 28) and visual acuity (n = 24). We removed six misfitting items, and the two factors of the revised LVIM demonstrated good rating scale function, good internal consistency (person reliability: visual field, .87; visual acuity, .90), good precision (person strata: visual field, 3.91; visual acuity, 4.40), no ceiling or floor effects, and no differential item functioning. CONCLUSION. The revised LVIM demonstrates good psychometrics on the Rasch model and can be used as a valid outcome measure in low vision rehabilitation.

To identify the inflammatory mediators around the time of pneumonia onset associated with concurrent or later onset of pressure ulcers (PUs).Retrospective.Acute hospitalization and inpatient rehabilitation unit of a university medical center.Individuals (N=86) with traumatic spinal cord injury (SCI) were included in the initial analyses. Fifteen of the 86 developed pneumonia and had inflammatory mediator data available. Of these 15, 7 developed PUs and 8 did not.Not applicable.Twenty-three inflammatory mediators in plasma and urine were assayed. The differences in concentrations of plasma and urine inflammatory mediators between the closest time point before and after the diagnosis of pneumonia were calculated.Initial chi-square analysis revealed a significant (P=.02) association between pneumonia and PUs. Individuals with SCI and diagnosed pneumonia had nearly double the risk for developing PUs compared with those with no pneumonia. In individuals with pneumonia, Mann-Whitney U exact tests suggested an association (P.05) between the formation of a first PU and a slight increase in plasma concentrations of tumor necrosis factor-alpha (TNF-α), and a decrease in urine concentrations of TNF-α, granulocyte-macrophage colony-stimulating factor (GM-CSF), and interleukin (IL)-15 after onset of pneumonia.These findings suggest that a relatively small increase in plasma TNF-α, and decreases in urine TNF-α, GM-CSF, and IL-15 from just before to just after the diagnosis of pneumonia could be markers for an increased risk of PUs in individuals with pneumonia after traumatic SCI.

To determine if the presence of pneumonia and pressure ulcers are associated in individuals with an acute spinal cord injury during acute care and rehabilitation hospitalizations.Retrospective, secondary analyses of data obtained from the Spinal Cord Injury Model Systems enrolled from 1993 until 2006 Setting: Acute care hospitalization and inpatient rehabilitation facilities Participants: A cohort of individuals hospitalized in acute care (n = 3,098) and inpatient rehabilitation (n = 1,768) was included in the analysis. Frequencies of pressure ulcer formation and episodes of pneumonia were noted in both settings.Not applicable.Pressure ulcer formation and diagnosis of pneumonia Results: The development of pressure ulcers, including stage I, was 20.3% acute care and 21.1% during in inpatient rehabilitation. Multivariate logistic regression analyses revealed a significant association of pneumonia with occurrence of pressure ulcers (P ≤ 0.001, OR = 2.3 and 2.2 respectively), the American Spinal Injury Association Impairment Scale grades (P 0.001), and utilization of mechanical ventilation (P 0.01) in both settings.A higher presence of pressure ulcers was found in individuals with pneumonia, after adjusting for injury severity, age, sex, and utilization of mechanical ventilation. Impaired inflammatory response and decreased mobility in individuals with pneumonia may predispose these individuals to develop pressure ulcers. Surveillance and preventive measures for pressure ulcers should be rigorous in individuals with SCI and pneumonia.

OBJECTIVE: To evaluate the validity of the Spinal Cord Injury Pressure Ulcer Scale (SCIPUS) during acute care and inpatient rehabilitation following spinal cord injury (SCI) by determining critical cutoff points and assessing the ability to predict risk for pressure ulceration (PrU). DESIGN: Retrospective. METHODS: Sensitivity, specificity, and area under the curve (AUC) for the receiver operating characteristic were determined for the scale’s ability to predict PrU 2-3 and 5-7 days after administrating the SCIPUS during acute care, and 5-7 and 14-21 days after administrating the SCIPUS during inpatient rehabilitation. RESULTS: During acute hospitalization, SCIPUS’s ability to assess risk for PrUs within 2-3 days was determined at cutoff score of 15 with 100% sensitivity and 75% specificity, AUC = 0.85. The scale was unable to assess PrU risk at 5-7 days, AUC < 0.6 at cutoff score of 13. During inpatient rehabilitation, the scale was unable to assess PrU risk at 5-7 and 14-21 days, AUC < 0.6 at cutoff score of 9. CONCLUSIONS: The SCIPUS could predict PrU occurring within 2-3 days following administration during acute, but unable to predict over a longer term within acute or inpatient rehabilitation. Improved PrU risk assessment following SCI may be possible with modification to the SCIPUS.

People with spinal cord injury (SCI) are predisposed to pressure ulcers (PU). PU remain a significant burden in cost of care and quality of life despite improved mechanistic understanding and advanced interventions. An agent-based model (ABM) of ischemia/reperfusion-induced inflammation and PU (the PUABM) was created, calibrated to serial images of post-SCI PU, and used to investigate potential treatments in silico. Tissue-level features of the PUABM recapitulated visual patterns of ulcer formation in individuals with SCI. These morphological features, along with simulated cell counts and mediator concentrations, suggested that the influence of inflammatory dynamics caused simulations to be committed to “better” vs. “worse” outcomes by 4 days of simulated time and prior to ulcer formation. Sensitivity analysis of model parameters suggested that increasing oxygen availability would reduce PU incidence. Using the PUABM, in silico trials of anti-inflammatory treatments such as corticosteroids and a neutralizing antibody targeted at Damage-Associated Molecular Pattern molecules (DAMPs) suggested that, at best, early application at a sufficiently high dose could attenuate local inflammation and reduce pressure-associated tissue damage, but could not reduce PU incidence. The PUABM thus shows promise as an adjunct for mechanistic understanding, diagnosis, and design of therapies in the setting of PU., Author Summary A virtual pressure ulcer was created as a platform to test therapies and determine the mechanisms most correlated with unfavorable outcomes. A layer of tissue fed with oxygen and diffusible molecules via blood vessels could develop an ulcer if pressure was applied, by simulating constriction of blood vessels in a circular region. Simulated ulcers were visually similar to digital photographs of ulcers in individuals with spinal cord injury in their irregular shapes, jagged edges, and overall progression in time. Statistical analyses of simulation outputs revealed that inflammation was an important determinant of ulcer severity and overall tissue damage. However, simulated clinical trials revealed that blocking the negative effects of inflammation could not prevent ulceration, and in order to be beneficial at all for this specific type of ulcer, anti-inflammatory treatments must be applied during the earliest stages of ulcer formation—before many clinical signs of ulceration appear.

Background The proposed Centers for Medicare & Medicaid Services (CMS) 30-day readmission risk standardization models for inpatient rehabilitation facilities establish readmission risk for patients at admission based on a limited set of core variables. Considering functional recovery during the rehabilitation stay may help clinicians further stratify patient groups at high risk for hospital readmission. Objective The purpose of this study was to identify variables in the full administrative medical record, particularly in regard to physical function, that could help clinicians further discriminate between patients who are and are not likely to be readmitted to an acute care hospital within 30 days of rehabilitation discharge. Design This study used an observational cohort with a 30-day follow-up of Medicare patients who were deconditioned and had medically complex diagnoses and who were receiving postacute inpatient rehabilitation in 2010 to 2011. Methods Patients in the highest risk quartile for readmission (N=25,908) were selected based on the CMS risk prediction model. Hierarchical generalized linear models were built to compare the relative effectiveness of motor functional status ratings in predicting 30-day readmission. Classification and regression tree analysis was used to create a hierarchical order among predictors based on variable importance in classifying patients based on readmission status. Results Approximately 34% of patients in the high-risk quartile were readmitted within 30 days. Functional outcomes and rehabilitation length of stay were the best predictors of 30-day rehospitalization. A 3-variable algorithm classified 4 clinical subgroups with readmission probabilities ranging from 28% to 75%. Limitations Although planned readmissions were accounted for in the outcome, potentially preventable readmissions were not distinguished from unpreventable readmissions. Conclusion For older patients who are deconditioned and have medically complex diagnoses admitted to postacute inpatient rehabilitation, information on functional status measures that are easily monitored by health care providers may improve plans for care transition and reduce the risk of hospital readmission.

The present study examines the predictive and incremental validity of Violence Risk Appraisal Guide scores in a sample of 328 male and 145 female jail inmates held on felony charges. Significant gender differences were observed in VRAG item and total score means, as well as in correlations between the VRAG and concurrent measures of aggression. VRAG scores significantly predicted institutional misconduct during incarceration and recidivism in the first year post-release for male inmates, but not for female inmates. In terms of incremental validity, VRAG scores predicted institutional misconduct and recidivism beyond that accounted for by psychopathy for male inmates, but not for female inmates. Implications for clinical practice and future research are discussed.