Clinical Instability as a Predictor of Negative Outcomes Among Elderly Patients Admitted to a Rehabilitation Ward

Objectives To assess the impact of clinical instability (CI) and delirium on admission to a rehabilitation unit on clinical and functional outcomes (death, transfer to acute care, poor functional recovery) at discharge, in a population of elderly patients. Design Observational study. Setting Rehabilitation and Aged Care Unit (RACU). Participants Participants were 583 consecutively and firstly admitted elderly patients. Measurements On admission, all patients underwent a comprehensive geriatric assessment including sociodemographics, cognitive and depressive symptoms, nutritional status, physical health, and functional status. CI was recorded for all patients on admission, assessing 5 vital signs (temperature, heart rate, systolic blood pressure, respiratory rate, and oxygen saturation). Delirium was assessed daily with the Confusion Assessment Method. Results Patients were on average old (mean age: 77.8 ± 9.8), predominantly female (68.6%), with mild cognitive deterioration (MMSE: 22.1 ± 6.3) and depressive symptoms (GDS: 5.9 ± 3.5). They had moderate comorbidity (means CIRS: 3.1 ± 1.9), and functional impairment both before (Barthel Index pre-admission: 84.5 ± 19.2; IADL: 3.3 ± 3.0) and on admission (Barthel Index: 55.8 ± 27.5). On admission, 136 (23.3%) patients were classified as clinically unstable: 76 (13%) had either CI or delirium, and 60 (10.3%) had CI associated to delirium. At discharge, 26 patients were transferred to acute care hospitals, and 14 died. Transfer to acute care occurred in more than 10% of patients with almost one altered condition (CI or delirium), and in one fifth of patients with the association of CI and delirium. In-RACU death was observed only in this latter group. Functional recovery at discharge was significantly higher in stable patients than in patients with CI and/or delirium. Conclusions CI and delirium are useful prognostic markers of adverse clinical and functional outcomes in a population of elderly subjects admitted to a rehabilitative unit.