The functional prognosis of older adults in a postacute care center: the impact of dementia

doi:10.21203/rs.3.rs-4909925/v1

Introduction: The functional recovery of older adults in postacute care units is influenced by demographic and clinical factors, including the presence of dementia. However, studies on this topic are scarce and do not often focus on this population.

Objective: The objective was to determine the influence of different factors on the functional prognosis, mortality and need for support at discharge of patients admitted to a postacute care centre, controlling for the presence of dementia.

Methods: We conducted a prospective observational study. We analysed the correlations between demographic and clinical factors and functional improvement (according to the Barthel Index, Tinetti test and Functional Ambulation Category scale), the need for support at discharge and mortality. We performed bivariate analysis followed by binary logistic regression or linear regression depending on the type of variable.

Results: A total of 206 patients were included. The presence of dementia and delirium were related to most outcome variables, so the sample was stratified according to the presence of dementia. After multivariate analysis, functional outcome of people with dementia was influenced by their previous autonomy and degree of improvement in hospital, the presence of delirium and anaemia on admission, as well as having a hearing deficit. The risk of death was associated with malnutrition, inflammation, antipsychotic treatment and having more functional losses prior to admission. People without dementia had better baseline functioning, influenced by few clear factors, where those with higher education and not married had better prognosis in autonomy and risk of falls and only malnutrition was a risk factor for mortality.

Conclusions: Dementia status is a determining factor for functional improvement, autonomy and mortality after admission to a postacute care unit. Differentiated risk algorithms for patients with and without dementia, would allow better targeting of functional rehabilitation.

dementia

delirium

rehabilitation

prognosis

postacute care

older adults

Older adults admitted to postacute care units exhibit high levels of frailty and a reduction in autonomy prior to admission (1). Physical rehabilitation improves final functionality, which is influenced by multiple demographic and clinical factors (2). However, the literature is limited and there is controversy about the degree to which these factors influence patient prognosis, making it difficult to apply clinical measures.

The presence of dementia increases the risk of femur fracture, hospital stay, mortality and dependence at discharge. Also, cognitive alterations after a stroke have been reported to be predictors of worse functionality in convalescence processes at discharge (3, 4). Delirium has been associated with low levels of physical activity in people with dementia who suffer a hip fracture and with less functional recovery in older patients admitted to postacute care units (5). Consequently, physical rehabilitation programs should consider patients’ cognitive status, including the presence of delirium, but further studies are needed.

The risk of falling is related to multiple pharmacological factors that can alter gait parameters (6). The use of antipsychotics is clearly related to an increased risk of falls and mortality, and their use should be accompanied by functional stimulation therapy (7). The use of anticholinergic drugs affects attention, working memory, and physical function and increases the length of hospital stay in people with dementia and delirium (8). However, much of the research in this field is biased by possible confounders, such as interactions with other drugs and comorbidities.

Other clinical factors, such as vestibular, visual, auditory and somatosensory impairments, account for 29% of gait and balance alterations (9). The presence of anaemia in older adults is also directly related to frailty (10). The serum albumin concentration is a predictor of mobility at hospital discharge in patients admitted for femur fracture and can predict the risk of developing delirium (11). On the other hand, the neutrophil-lymphocyte index is an increasingly used marker for measuring inflammatory parameters, and higher levels are associated with worse physical recovery 3 months after intensive care unit (ICU) admission (12). The application of physical restraints has also been associated with negative outcomes (13, 14). In addition, patient sex influences rehabilitation outcomes in general hospitals, with men having a lower risk of frailty but a greater risk of mortality one year after admission and women having a greater risk of institutionalization but a lower risk of readmission (15). Despite these findings, there is little literature on rehabilitation in older adults admitted to postacute care facilities.

Given the paucity of studies on rehabilitation in older adults, especially in postacute care units, the main objective of this study was to determine the influence of different sociodemographic and clinical factors on the functional prognosis, mortality and need for support at discharge of patients admitted to a postacute care centre, controlling for the presence of dementia.

1. Study design, ethics and participants

We carried out a prospective observational study at the Monterols Postacute Care Center in Reus (Spain) with the approval of the corresponding ethics committee (Institut d'Investigació Sanitària Pere Virgili). Patients who were admitted to the convalescent and psychogeriatric units from September 2018 to January 2020 (the end date was selected due to the start of the COVID-19 pandemic) were consecutively included. Patients who did not provide informed consent, who were admitted for palliative care or who had verbal comprehension or expression difficulties were excluded. All participants, or a family member or guardian in the case of cognitive impairment, signed the informed consent form prior to study participation.

2. Evaluation instruments

2.1 Clinical and sociodemographic variables

We obtained the following data from the patients’ electronic health records: place of residence and necessary level of support prior to admission and at discharge; history of visual or hearing impairment; the prescription of antipsychotics, benzodiazepines, opiates, antidepressants, proton pump inhibitors (PPIs), clomethiazole and anticholinergics (according to the Anticholinergic Cognitive Burden Scale (16)) at admission and discharge; the Charlson Comorbidity Index score (17); the number of falls and the use of physical restraints during hospitalisation. From the initial blood test, we obtained haemoglobin, albumin, creatinine, glucose, sodium, and potassium levels, lymphocyte and neutrophil counts and the consequent neutrophil/lymphocyte ratio (18).

The presence of dementia was determined by the Informant Questionnaire on Cognitive Decline in the Elderly Spanish version (S-IQCODE), using a score > 85 as the cut-off point (19). The presence of delirium was determined according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria (20).

We evaluated functional status in activities of daily living at admission and at discharge by the Barthel Index (21), with scores ranging from 0 to 100 (from the lowest to highest functional ability), the Tinetti test (22) to determine the risk of falling, with a minimum score of 0 and a maximum score of 28 (from the lowest to highest risk), and the Functional Ambulation Category (FAC) (23) to establish ambulation prior to the acute state that required admission, with a score of 5 indicating ambulation without support and a score of 0 indicating the inability to walk without external help.

3. Procedures

Patients were evaluated during the first 48 hours after admission. A psychiatrist evaluated the presence of delirium, and the treating physiotherapist administered the Tinetti and FAC scales; additionally, a relative of the patient was interviewed to complete the S-IQCODE. The occupational therapy team administered the Barthel Index scale. A member of the research team collected data on sociodemographic characteristics, prescribed medications and analytical parameters.

The Tinetti test, FAC and Barthel Index scores were reassessed at discharge, defined as the time when the patient left the centre as determined by the treating team. To determine the change in functionality during admission, the variations in the Barthel Index, Tinetti test and FAC scores were determined by subtracting the value obtained at the time of the initial test from that obtained at the time of discharge from the centre. The destination, whether to a residential centre or home, was recorded at discharge and, in the latter case, whether no help was required (autonomous at home), whether regular assistance was required at specific times (occasional home support) or whether help was required 24 hours a day (high dependency at home). We also recorded whether the patient died during hospital admission, in which case assessments with the Barthel, FAC and Tinneti scales at discharge were not possible, nor did we record the drugs prescribed at discharge due to the specific characteristics of the pharmacological treatment of terminally ill patients, in these cases we only considered the values collected at admission.

4. Statistical analysis

The following were defined as dependent variables: variations in the FAC, Tinetti, and Barthel Index scores, autonomous at home after discharge, occasional support at home after discharge, high dependency at home after discharge, discharge to home and death. For bivariate analyses of continuous vs. categorical variables, we used the Mann‒Whitney or Kruskal–Wallis U test (more than two categories) or Student’s t test in the case of normality, the Spearman or Pearson test (according to normality) for comparing two continuous variables, and the chi-square test for comparing two categorical variables.

We performed linear regression for the quantitative dependent variables and binary logistic regression for the qualitative variables, stratifying the sample according to the presence of dementia (explained below). These regressions were carried out in a “backwards” or “backwards Wald” format with numerous models (between 6 and 11). The reference level for the sex variable was "woman". Collinearity was considered when choosing the quantitative variables to include in the regressions since the linear relationship between variables can be confusing in the analysis.

Statistical significance was defined as p < 0.05. We used the statistical program SPSS 27.0 (Statistical Package for the Social Sciences version 27.0).

We recruited 238 patients; 32 patients were excluded because they did not provide informed consent or had verbal comprehension or expression difficulties. Therefore, we included 206 individuals in the analysis. People with dementia (56% of the sample) had greater dependence for ambulation before the acute episode leading to admission (according to the FAC score) and were more likely to be institutionalised or require more intensive support at home (Table 1). However, at admission, patients with dementia had a better score on the Tinetti scale (a lower risk of falls) than people without dementia. People with dementia also had less visual impairment, more frequent delirium, a greater anticholinergic burden, more antipsychotic use and less use of benzodiazepines and opiates than people without dementia.

Table 1. Clinical and demographic characteristics of study participants at admission, divided according to the presence of dementia.

	Whole sample (n=206)	No dementia (n = 98)	Dementia (n=108)
Age (years)* Female sex Years of study	77.95 ± 9.82 91 (44.2%) 7.02 ± 4.21	75.61 ± 10.40 41 (41.8%) 7.16 ± 3.24	80.06 ± 8.80 50 (46.3%) 6.89 ± 4.94
Marital Status Single Married Separated Widowed	18 (8.7%) 83 (40.3%) 21 (10.2%) 18 (8.7%)	11 (11.2%) 39 (39.8%) 12 (12.2%) 36 (36.7%)	7 (6.5%) 44 (40.7%) 9 (8.3%) 48 (44.4%)
Place of residence*
Autonomous at home	76 (36.9%)	51 (52%)	25 (23.1%)
Occasional support at home	97 (47.1%)	44 (44.9%)	53 (49.1%)
High dependence at home	25 (12.1%)	3 (3.1%)	22 (20.4%)
Residence	8 (3.9%)	0 (0%)	8 (7.4%)
Clinical characteristics
Delirium	62 (30.1%)	14 (14.3%)	48 (44.4%)
Charlson Comorbidity Index	2.88 ± 2.35	2.98 ± 2.42	2.80 ± 2.30
Previous FAC*	3.57 ± 1.38	3.76 ± 1.35	3.41 ± 1.39
Initial Barthel Index score	43.28 ± 27.79	44.49 ± 25.85	42.18 ± 29.53
Initial Tinetti score*	9.33 ± 10.38	7.09 ± 9.86	11.35 ± 10.47
Visual impairment*	143 (69.4%)	75 (76.5%)	68 (63%)
Hearing impairment	53 (25.7%)	22 (22.4%)	31 (28.7%)
Analytics values Haemoglobin. g/dl*	11.63 ± 1.77	11.30 ± 1.76	11.92 ± 1.73
Albumin. g/dL*	3.64 ± 0.56	3.53 ± 0.44	3.73 ± 0.64
Creatinine. mg/dL	1.12 ± 0.52	1.15 ± 0.58	1.10 ± 0.45
Glucose. mg/dL	110.08 ± 45.92	111.89 ± 49.42	108.43 ± 42.66
Sodium. (mEq/L) *	137.24 ±3.95	136.27 ± 4.18	138.12 ± 3.51
Potassium. (mEq/L)	4.43 ± 0.55	4.46 ± 0.59	4.41 ± 0.50
N/L ratio*	3.36 ± 3.01	3.85 ± 3.40	2.91 ± 2.51
Prescribed medications
ACB score*	2.19 ± 1.88	1.64 ± 1.92	2.69 ± 1.69
Antipsychotics*	96 (46.6%)	28 (28.6%)	68 (63%)
Benzodiazepines*	57 (27.7%)	35 (35.7%)	22 (20.4%)
Antidepressants	57 (27.7%)	25 (25.5%)	32 (29.6%)
PPIs	142 (68.9%)	73 (74.5%)	69 (63.9%)
Clomethiazole	52 (25.2%)	19 (19.4%)	33 (30.6%)
Opiates*	29 (14.1%)	20 (20.4%)	9 (8.3%)

The results are reported as frequencies (percentages) for discrete variables and means ± standard deviations for continuous variables. N/L: ratio: Neutrophil/Lymphocyte ratio. ACB: Anticholinergic Cognitive Burden scale. PPI: Proton Pump Inhibitors. *p<0.05

In bivariate analysis between the outcome variables and each of the possible predictor variables, we found a relationship between most of the outcome variables and dementia and delirium state. Given the known high collinearity between delirium and dementia, we decided to control for the presence of dementia, again performing bivariate analysis after dividing the sample according to its presence (Supplementary Table 1). We obtained significant results for the total sample or for one of the two subsamples (with or without dementia) for the following variables: education level, length of hospital stay, visual and hearing impairment, female sex, age, use of opiates at discharge, use of benzodiazepines at discharge, use of PPIs at discharge, use of antipsychotics at admission and at discharge, use of clomethiazole at discharge, ACH scale score at admission and at discharge, use of antidepressants at discharge, the three functional scale scores at admission (FAC scale, Tinetti scale and Barthel Index), Tinetti and Barthel Index score variations, creatinine level, albumin level, glucose level, sodium level, haemoglobin level, the neutrophil–lymphocyte ratio, autonomous and high dependence at home prior to admission and a widowed, separated and single marital status.

In subsequent analyses, we separately analysed the subsamples with and without dementia. According to the linear regression, FAC score variation remained related to the number of years of education and visual impairment in individuals without dementia; however, no significant correlations were detected in the individuals with dementia. The Barthel Index score variation remained related to the length of hospital stay in the individuals without dementia and was inversely related to haemoglobin levels and delirium in the individuals with dementia, and the Tinetti score variation was related to a widowed marital status in the individuals without dementia and with a previous autonomous status at home in the individuals with dementia (Table 2).

Table 2. Linear logistic regression for functional outcome variables in the sample divided according to the presence of dementia.

		No dementia (1)				Dementia (2)
		B	Standard error	p	β	B	Standard error	p	β
FAC variation ¹	Creatinine Years of					-0.321	0.168	0.059	-0.206
	Education	0.097	0.037	0.010	0.286
	IBP	-0.582	0.305	0.060	-0.207
	Visual impairment	0.755	0.284	0.010	0.288
Barthel Variation ²	Length of stay (days)	0.066	0.031	0.036	0.246
	Haemoglobin Delirium					-1.917 -5,377	0.782 2.691	0.016 0.049	-0.255 -0.208
Tinetti Variation ³	Widowed	4.463	2.054	0.033	0.250
	Autonomous (previous)					4.982	1.826	0.008	0.287

PIP:Proton Pump Inhibitors

¹FAC score variation. (1) Subsample without previous dementia 4 models. R² adjusted 0.162. ANOVA F 5.647 p 0.002.(2)Subsample with previous dementia 6 models. R² adjusted 0.031. ANOVA F 3.668 p 0.059.

² Barthel Index score variation.(1) 9 models. R² adjusted 0.047 ANOVA F 4.581 p 0.036 (2) 9 models. R² adjusted 0.118 ANOVA F 5.497 p 0.006.

³Tinetti score variation.(1) 9 models. R² adjusted 0.049 ANOVA F 4.722 p 0,033.(2) 9 models. R² adjusted 0.071 ANOVA F 7.442 p 0.008

According to the binary logistic regression of destination at discharge, occasional home support was related in both subsamples to having the same support at home prior to the current hospitalisation, in the subsample without dementia was inversely related to being single or separated and almost significantly to the use of antipsychotics at discharge, and in the subsample with dementia to Barthel Index score variation and inversely related (almost significantly) to delirium. Discharge to home without third-party support was correlated with a single or separated marital status in the sample of patients without dementia, but there was no correlation in the sample of patients with dementia. A high level of dependency at home at discharge was related to hearing impairment in patients with dementia. Admission to a residential resource at discharge was related to the length of hospital stay in the two subsamples, to lower creatinine levels in patients without dementia and to delirium in patients with dementia. Mortality was inversely correlated with the serum albumin concentration in the two subsamples and with the FAC score prior to admission, the neutrophil/lymphocyte ratio, and the prescription of antipsychotics at the time of admission to the centre and negatively correlated with the initial Barthel Index score in the subsample with dementia (Table 3).

Table 3. Binary logistic regression for the destination at discharge or death in the sample divided according to the presence of dementia

		No dementia (1)					Dementia (2)
		B	Error standard	p	Exp (B)	95% IC inf-sup	B	Error standard	p	Exp (B)	95% IC Inf-sup
Occasional support at home ¹	Separated Single	-2.230 -2.465	0.857 0.949	0.007 0.009	0.097 0.085	0.018-0.522 0.013-0.546
	Use of antipsychotics aat discharge	-1.334	0.694	0.055	0.264	0.068-1.026
	Previously occasional ssupport	1.688	0.703	0.016	5.408	1.362-21.46	2.707	0.623	<0.001	14.98	4.420-50.75
	Barthel index score vvariation N/L ratio Delirium						0.061 -0.321 -1.185	0.026 0.192 0.619	0.020 0.095 0.056	1.063 0.726 0.306	1.010-1.118 0.498-1.058 0.091-1.030
Autonomous at home²	Single	2.708	0.966	0.005	15.00	2.258-99.63
	Separated	2.485	0.856	0.004	12.00	2.240-64.28
	Previously autonomous N/L ratio	20.33	5465.5	0.997	67710	0.000-	18.26 0.419	4287 0.550	0.997 0.446	85520 1.521	0.000- 0.517-4.472
High dependency at home ³	Hearing impairment						1.247	0.571	0.029	3.478	1.137-1.644
Residence⁴	Sodium	0.349	0.205	0.089	1.418	0.948-2.119
	Creatinine Delirium Length of stay (days) Barthel variation	-5.444 2.655 0.024 -0.096	2.530 1.594 0.011 0.054	0.031 0.095 0.027 0.076	0.004 14.36 1.024 0.908	0.000-0.616 0.632-326.7 1.003-1.046 0.817-1.010	1.189 0.017 -0.060	0.528 0.007 0.033	0.024 0.015 0.067	3.282 1.017 0.942	1.167-9.233 1.003-1.031 0.884-1.004
Death⁵	Albumin	-2.144	0.853	0.012	0.117	0.022-0.624	-1.519	0.695	0.029	0.219	0.056-0.855
	Previous FAC score	-0.387	0.217	0.074	0.679	0.444-1.039	0.687	0.349	0.049	1.989	1.004-3.938
	Barthel index score at admission						-0.055	0.021	0.009	0.946	0.908-0.987
	N/L ratio						0.308	0.132	0.019	1.361	1.051-1.761
	Use of antipsychotics at admission						2.303	0.933	0.014	9.999	1.607-6.205

PPIs: Proton Pump Inhibitors. N/L ratio: Neutrophil/Lymphocyte ratio

¹Occasional support at home:(1) Hosmer-Lemeshow test X² 6.473 p 0.263. R² Cox-Snell 0.346. R² Nagelkerke 0.478. 11models.(2) Hosmer-Lemeshowtest X² 2.717 p 0.910. R² Cox-Snell 0.389. R² Nagelkerke 0.520. 9 models.

²Autonomous at home: (1) Hosmer-Lemeshow test X² 0.000 p 1.000. R² Cox-Snell 0.326. R² Nagelkerke 0.553. 9 models. (2)Hosmer-Lemeshow test X² 0.713 p 0.999. R² Cox-Snell 0.103 R² Nagelkerke 0.611. 10 models.

³High dependence at home: (1) Hosmer-Lemeshow test X² 0.000 . R² Cox-Snell 0.048. R² Nagelkerke 0.266. 6 models. (2)Hosmer-Lemeshow test X² 0.000 . R² Cox-Snell 0.043 R² Nagelkerke 0.077. 4 models.

⁴Residence.(1)Hosmer-Lemeshow test X² 1.173 p 0.997 . R² Cox-Snell 0.260. R² Nagelkerke 0.555. 3 models. (2)Hosmer-Lemeshow test X² 10.032 p 0.187 . R² Cox-Snell 0.218 R² Nagelkerke 0.302. 5 models.

⁵Death: (1)Hosmer-Lemeshow test X² 7.803 p 0.453. R² Cox-Snell 0.114. R² Nagelkerke 0.218. 8 models. (2)Hosmer-Lemeshow test X² 4.289 p 0.830 . R² Cox-Snell 0.220 R² Nagelkerke 0.398. 5 models. Cox-Snell 0.291. R² Nagelkerke 0.536. 7 models. (2)Hosmer-Lemeshow test X² 0.000. R² Cox-Snell 0.047 R² Nagelkerke 0.114. 11 models

In this study, we evaluated how different demographic and clinical factors influenced the prognosis of patients admitted to a postacute unit. Notoriously, dementia and delirium had a significant association with most functional and discharge destination outcomes, which is in line with previous reports (24, 25)(4, 26, 27). When controlling by dementia status and after regression analysis, functional improvement remained influenced by different variables in people with and without dementia.

In people with dementia, lower haemoglobin levels and the presence of delirium at admission negatively affected improvement in activities of daily living (according to the Barthel Index) and a better baseline status, reflected by no previous need for support at home, predicted better outcomes in terms of fall risk according to the Tinetti score. Also, a greater improvement of activities of daily living predicted a higher likelihood of returning home with only occasional support and having delirium at admission was related to a higher probability of requiring institutionalised support. Worse functional outcomes were previously described in people with or without dementia who suffer from delirium (28), although we did not observed this association in people without dementia perhaps because of their lower prevalence of delirium. Also, previous reports associated haemoglobin with worse functional outcomes, frailty, longer hospital stays and mortality (10, 29, 30). Preventing and treating anaemia and delirium may be feasible actions to improve functional prognosis, especially in populations with poorer baseline status and efforts to improve daily living skills would increase the likelihood of people with dementia returning home with more autonomy.

Also in people with dementia, longer length of hospitalisation was associated with a higher probability of institutionalisation, as previously described (31) and having a hearing deficit was associated with returning home with the greatest need for assistance, which may be related to the motor and gait impairments reported to be associated with this deficit (9), which can lead to increased functional impairment, falls and death (32, 33). Furthermore, having a worse baseline functionality (according to Barthel score) and perhaps greater deterioration in their walking ability at admission (interpreted by their better preadmission FAC scores) were also associated with increased mortality, which is consistent with findings from previous studies reporting disability in activities of daily living and gait disturbances as risk factors for death (34–37). Mortality was also influenced by known markers of increased risk: lower albumin levels (marker of malnutrition)(38), higher neutrophil-lymphocyte ratio (inflammatory marker)(39), additionally to the use of antipsychotic drugs, repeatedly identified as a risk factor for death (7, 40, 41).

In patients without dementia, a longer length of hospital stay correlated with greater functional improvement according to the Barthel Index, possibly because it implies more stabilisation time, but similarly to patients with dementia, was also associated with a higher probability of institutionalisation. Additionally, patients with visual impairment were closer at discharge to their previous levels of walking autonomy, perhaps because the offsets acquired for this deficit would facilitate rehabilitation, although more specific studies are needed. The relationship we found between a greater improvement in ambulation (FAC score) and a higher education level has been previously described in patients admitted to the ICU (42), possibly due to the greater motivation for rehabilitation, as well as a greater capacity to acquire new strategies.

Also, in people without dementia, a widowed marital status was associated with a greater improvement in fall risk (Tinetti scale score). It is known that the risk of hospitalisation for external causes increases two months after widowhood (43), which could imply that the risk of falling may have interfered with hospitalisation and increased susceptibility to rehabilitation. Also, single or separated non-demented people were more likely to return home as self-sufficient, which can be associated with a higher previous functional status that allowed them to live alone, although future work is needed to analyse nonspousal support (44).

Although better renal function has been associated with better outcomes after cardiac intervention (45) or stroke (46), in our sample without dementia higher creatinine levels (which can be a sign of worse renal function) correlated only with a lower likelihood of requiring residential care but not with other outcomes, a finding that is difficult to interpret and would probably require a larger sample. Mortality in non-demented patients correlated only with lower serum albumin levels, aspect shared with the dementia subgroup.

Distinct factors affecting people with and without dementia present an opportunity for differentiated healthcare plans. People with dementia were more influenced by their previous autonomy and degree of improvement in hospital, where prevention and treatment of delirium and anaemia interfering with functional improvement and correction of hearing deficits associated with a greater need for support would improve their functional prognosis. Prevention and treatment of malnutrition, inflammation and optimisation of antipsychotic treatment would reduce death risk, especially in those with more functional losses prior to admission.

In contrast, in people without dementia who tend to have better baseline functioning, few clear factors are influential, where those with higher education and not-married had a better prognosis in autonomy and risk of falls and only malnutrition was a risk factor for mortality. In non-dementia populations, more efforts should be made to communicate and motivate people with lower education and those requiring regular support from third parties.

As limitations, we highlight that the unit has patients admitted for a wide variety of pathologies, which makes it difficult to generalise functional assessments. We did not perform a cluster analysis of factors that could interact with each other to influence patient prognosis and dementia subtypes and severity were also not considered. However, the heterogeneity, high comorbidity and polypharmacy of the study population facilitate the extrapolation of the results to other complex clinical settings. Also, we analysed not only functionality as measured by three well-known scales, but also autonomy in the real-world according to the support people need after hospitalisation.

Dementia and delirium are determinant in the potential for functional improvement and the risk of death after admission to a postacute care unit. The prognosis of people with and without dementia is determined by a distinct combination of clinical and demographic factors. Future studies should address the interactions between these factors and the weight of each factor in specific clinical and demographic contexts and thus develop risk algorithms differentiated according to the presence of dementia to better target rehabilitation processes.

FAC

Functional Ambulatory Category

ACH

Anticholinergic

ACB

Anticholinergic Cognitive Burden scale

N/L ratio

Neutrophil/lymphocyte ratio

PPI

Protom Pumb Inhibitor

Ethics approval and consent to participate

The study was approved by the ethics committee of the Institut d'Investigació Sanitària Pere Virgili, Reus (Spain). Ref. CEIM: 131/2018.

Consent for publication

Not applicable

Funding

This work was supported by Mutuam Conviure Foundation (19 premis de recerca, 2019). The Mutuam Conviure Foundation did not participate in the study design, in the collection, analysis and interpretation of data, in the writing of the report or in the decision to submit the article for publication.

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No competing interests reported.

SupplementaryTables.docx

The functional prognosis of older adults in a postacute care center: the impact of dementia

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Abstract

INTRODUCTION

METHODOLOGY

RESULTS

DISCUSSION

CONCLUSION

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

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Version 1