Can I Discharge My Stroke Patient Home After Inpatient Neurorehabilitation? LIMOS Cut-Off Scores for Stroke Patients “Living Alone” and “Living With Family”

 Of course you can. With your effective stroke rehab protocols in the hospital and the ones you are sending home with them they will soon be back to 100% recovery. OH, YOU DON'T HAVE THAT? Well, what the fuck are you doing to get there?

Can I Discharge My Stroke Patient Home After Inpatient Neurorehabilitation? LIMOS Cut-Off Scores for Stroke Patients “Living Alone” and “Living With Family”

Beatrice Ottiger¹, Dirk Lehnick², Tobias Pflugshaupt¹, Tim Vanbellingen^1,3 and Thomas Nyffeler^1,3*

• ¹Neurocenter, Luzerner Kantonsspital, Lucerne, Switzerland
• ²Clinical Trial Unit Central Switzerland, University of Lucerne, Lucerne, Switzerland
• ³ARTORG Center for Biomedical Engineering Research, Gerontechnology and Rehabilitation Group, University Bern, Bern, Switzerland

Background: Discharge planning of stroke patients during inpatient neurorehabilitation is often difficult since it depends both on the patient's ability to perform activities of daily living (ADL) and the social context. The aim of this study was to define ADL cut-off scores using the Lucerne ICF-based multidisciplinary observation scale (LIMOS) that allow the clinicians to decide whether stroke patients who “live alone” and “live with a family” can be discharged home or must enter a nursing home. Additionally, we investigated whether age and gender factors influence these cut-off scores.

Methods: A single-center retrospective cohort study was conducted to establish cut-off discharge scores for the LIMOS. Receiver-operating-characteristics curves were calculated for both patient groups “living alone” and “living with family” to illustrate the prognostic potential of the LIMOS total score with respect to their discharge goals (home alone or nursing home; home with family or nursing home). A logistic regression model was used to determine the (age- and gender-adjusted) odds ratios of being released home if the LIMOS total score was above the cut-off. A single-center prospective cohort study was then conducted to verify the adequacy of the cut-off values for the LIMOS total score.

Results: A total of 687 stroke inpatients were included in both studies. For the group “living alone” a LIMOS total score above 158 indicated good diagnostic accuracy in predicting discharge home (sensitivity 93.6%; specificity 95.4%). A LIMOS total cut-off score above 130 points was found for the group “living with family” (sensitivity 92.0%; specificity 88.6%). The LIMOS total score odds ratios, adjusted for age and gender, were 292.5 [95% CI: (52.0–1645.5)] for the group “living alone” and were 89.4 [95% CI: (32.3–247.7)] for the group “living with family.”

Conclusion: Stroke survivors living alone needed a higher ADL level to return home than those living with a family. A LIMOS total score above 158 points allows a clinician to discharge a patient that lives alone, whereas a lower LIMOS score above 130 points can be sufficient in a patient that lives with a family. Neither age nor gender played a significant role.

Introduction

The planning of discharge during inpatient neurorehabilitation in stroke patients is a dynamic process and critically depends on the patients' functional progress and ability to perform activities of daily living (ADLs). In addition to performance in ADL, various factors such as demographic background, age, gender, access to municipal organizations and the social context also plays an important role in deciding whether a patient can return home or must enter a nursing home (1, 2). Previous studies emphasized that one of the strongest factors of being discharged home or not is the living situation [i.e., if a patient lives alone or with a family (3–5)]. Stroke survivors often require the assistance of family caregivers to cope with their physical, cognitive and emotional deficits at home (6, 7). After inpatient neurorehabilitation, patients who have a caregiver at home are therefore more likely to be discharged home (3, 4) than patients living alone (1, 3, 4, 8). For instance, although stroke survivors living alone can partially be supported by community or professional organizations, they lack the twenty-four-seven support of a person living in the same household. This suggests that to be discharged home, a stroke patient living alone must show better performance in the activities of daily living (ADLs; e.g., moving around at home, preparing a meal etc.) than a stroke patient living with a family. This is particularly relevant for Switzerland, since a third of the Swiss population lives alone (9). This trend is also steadily increasing worldwide (10, 11).

Therefore, it is important to continuously assess ADL performance of inpatients during neurorehabilitation and to estimate performance levels sufficient for returning home. To accurately measure the ability of ADL performance according to the International Classification of Functioning, Disability and Health (ICF) framework set by the World Health Organization (WHO), we recently developed the Lucerne ICF-based Multidisciplinary Observation Scale (LIMOS) and validated it in stroke patients (12). Using this scale, patients with stroke are observed with respect to their activity ability by health professionals involved in their neurorehabilitation (nurses, physiotherapists, speech therapists, occupational therapists, as well as neurologists). This will be done in the first 72 h after admission, then weekly during the stay and in the last 72 h before discharge from inpatient neurorehabilitation. The observations are structured and consist of 45 basic and instrumental ADL items based on the (ICF) framework, which are categorized in four factors (interpersonal activities, motor and self-care; communication; knowledge and general tasks; and domestic life). The LIMOS measures the level of assistance needed from the health professionals, with higher scores representing more independence (12). As each discipline rates their own subpart within the whole LIMOS, it is easy and short to conduct and requires only 5 to 10 min per discipline. The advantage of LIMOS is that it is more comprehensive and more sensitive than the Functional Independence Measure (FIM) and Barthel Index (BI) (13). In addition, the LIMOS scale shows neither floor nor ceiling effects at admission and discharge, in contrast, to the FIM and BI (12, 13). Using the LIMOS thus allows the patients' activity levels to be assessed comprehensively.

Based on previous studies suggesting that ADL performance and living situations are crucial factors to be able to return home after stroke neurorehabilitation (1, 5), the aim of the present study was to define LIMOS cut-off scores in ADL performance for stroke patients living alone and those living with a family. Such scores would provide clinicians a tool that facilitates the decision concerning the discharge destination during inpatient rehabilitation. A second aim was to verify whether the factors age and gender influence these cut-off scores because previous studies have found that older people and women had a worse prognosis for returning home after stroke (1, 14, 15).