Stroke Rehabilitation in a Geriatric Day Hospital

Journal of the Hong Kong Geriatrics Society • Vol. 11 N o.1 Jan. 2 00 2 

STROKE REHABILITATION IN A GERIATRIC DAY HOSPITAL: FUNCTIONAL GAIN, ITS MAINTE AINTE NANC NANCE AT 6 MONTHS ON THS POS T-DIS CHARG HARGE E KW Lee. MRCP (UK), FHKAM (Med) M edical O fficer  fficer 

CKW Pei. MRCP (UK), FHKAM (Med) Senior Medica l O fficer  fficer 

FHW Chan. MRCP (Ireland), FHKAM (Med) C hief of Services  Services  Depa rtment rtment of M edic ine and G eriatrics, eriatrics, Fung Fung Yiu King Ho spital, Hong Kong 

JHK Geriat Geriatrr Soc Soc 20 02 ; 1 1:2 8-32  8-32  Co rres rrespond pond ence: Dr. KW KW Lee  Email: [email protected] 

Summary  Reha bilitatio bilitation n at Geriatric Geriatricss Day Hosp ital (GD (GDH) H) h a s b e e n s h o w n t o im im p r ov ov e f u n c t io i o n a l ou ou t c om om e am ong stroke stroke patients, yet w hether the the improvemen improvemen t  c a n b e m a i n t a in in e d b y 6 m o n t h s a f t e r d i s c h a r g e is is u n k n o w n . A p ro ro s p e ct c t iv iv e s t u d y w a s p e rf rf or or m e d t o e x a m in e t h e f u n c t io io n a l o u t co co m e o f s t ro ro k e p a t ie ie n t s re h a b i li lit a t e d a t G DH DH a n d a g a i n a t 6 m o n t h s p o s t   disch arge. 50 e lde rly w ere included included pros pros pectively. pectively. T h e r e w a s a g a i n o f 8 . 5 p o in in t s o n t o ta ta l Fu Fu n c t io io n a l  Ind  Ind epen den t Meas uremen t (FI (FIM) M) score score over a m edian p e r io io d o f 1 2 w e e k s . T h e g a i n i n F IM IM c or or re re l a t e d   p o s i t iv i v e l y w i th t h n u m b e r o f a t t e n d a n c e (r (r =0 =0 . 4 9 ,  p<0.0  p<0.0 01 ) an d len gth of sta y (r= (r=0.4 2, p=0.0 p=0.0 02 ). There w as a n on-signif on-signifiicant d rop rop of FIM FIM score score by 1.4 a t 6  m o n t h s . Pa Pa t i e n t s w h o w e r e co co g n it it iv iv e l y i m p a i re re d   (AMT  ≤6) did s imilar imilar w ith their cognitively cognitively norma l (AMT >6) >6) counte rparts. W e conclud conclud ed th at fu nctional outcom outcom e is m aintained w ith s troke troke rehab ilitati litation on at  GDH GDH at 6 m onths an d cogniti cognitive ve impairm impairm ent s hould  not be a h ibd ran ce to he a cces cces s of the s ervice. ervice.   K e y w o r d s : stroke rehabilitation, geriatric day hospital, cognitive impairment 

d o m i c il il ia ia r y a n d h o s p i t a ll- b a s e d s e r v ic ic e s , a n d s o m e frail elderly patients might have benefited from t r a i n in in g i n a d a y h o s p it it a l s e t t in in g . F u r t h e r m o r e , H u i 5 e t a l r e p o r t ed ed a p r o s p e c t iv ive r a n d o m i s ed ed s t u d y t h a t r e v ea ea l e d fu fu n c t i on on a l im im p r o v e m e n t b e i n g g r e a t e r i n the group managed by geriatricians with day hosp ital facil facility ity comp comp ared with with th e conventional inp a t i en en t g r ou ou p a t 3 m o n t h . Th e r e i s o n l y li lim i t e d d a t a o n t h e m a in t e n a n c e o f t h e fu f u n c t i o n a l g a i n a ft e r s t r o k e r e h a b i li li t a t io io n . Garraway et al 6 found that the improvement in functional outcome at the time of discharge from h o s p i t a l w ou ou l d d is is a p p e a r b y on on e y e a r . W it it h in a n increa singly cost-cons ciou ciou s s ociety, ociety, it it would b e very very u n d e s i r a b l e if if t h e s c a r c e r e s o u r c e s i n v es es t e d o n l y r e s u l t e d in in a t r a n s i en en t i m p r o v em em e n t in in t h e p a t i en en t s and the effect would soon disappear after the cessation of treatment. Therefore we conducted a prospective study to: (1) determine the functional gain and more im p o r t a n t l y, y, it it s m a i n t e n a n c e s ix ix m o n t h s a ft e r t h e completion completion of th e reha bilitation bilitation program for pat ients with a primary diagnosis of cerebral vascular accident accident who u nd erwent reha bilitati bilitation on in a geriatric geriatric day h ospital; an d (2) to in in vestigate factors factors affecting affecting the maintenance of functional independence.

Introduction:

G e r ia ia t r i c d a y h o s p i t a l h a s d i ff ffe r e n t r o le le s i n a n elderly health service as defined by Brocklehurst a n d Tu c k e r 1 . Rehab ilitatio ilitation n is on e of th e im im porta nt o b j e c t i v e s s t a t e d . A s r e p o r t e d b y L e u n g e t a l 2, geriatric day hospital in Hong Kong played an i m p o r t a n t r o l e in in s t r o k e r e h a b i li li t a t io io n . H o w e ve ve r , controversies about the effectiveness of stroke r e h a b i l i t a t i o n i n a d a y h o s p i t a l s e t t i n g s t i l l e x i st . You ng et a l 3 foun d tha t home ph ysiotherapy ysiotherapy seemed to be slightly more effective and more resource efficient than day hospital attendance. They s u g ge ge s t e d t h a t h o m e p h y s i ot ot h e r a p y s h o u l d b e t h e p r e f er er r e d r e h a b i l it it a t i o n m e t h o d fo r a f t e r c a r e o f   s t r o k e p a t i en en t s . O n t h e o t h e r h a n d , G la la d m a n e t a l 4 s h o w e d n o d i ff ffe r e n c e i n t h e e ff ffe c t i ve ve n e s s o f t h e

28

Methods

E l d e r ly ly p a t i en en t s a g e d ≥6 5 w h o w e r e r e fe fe r r e d t o GDH for for reh ab ilitation ilitation with th e prin ciple ciple diagnosis o f s t r o k e d u r in in g t h e p e r io io d J u n e 1 9 9 6 t o J a n 1 9 9 8 were recruited. Th Th ey were eith eith er pa tients wh o were were d i s c h a r g e d fr f r o m a n i n p a t i e n t g e r ia ia t r i c u n i t , o r patients referred from the geriatric specialist o u t p a t i en en t c li li n ic ic . Th Th e i r d e m o g r a p h ic d a t a , n u m b e r of m edical diagnoses , ab breviated m ent al test (AMT) MT) s c o r e s a n d s o c ia ia l b a c k g r o u n d s w e r e r e c or or d e d . Multi-disciplinary assessment was carried out fo r e a c h p a t i e n t a n d fu n c t i on o n a l p r o b le le m s w e r e identified. Case conferences were held where

KW Lee et al • Stroke Rehabili tation and G DH 

treatm ent plan wou ld be formu lated. Patients would be discharged from the day hospital if their fu n c t i o n a l p r o b l e m s w e r e s o lve d , p r e - s e t a i m s ach ieved, or if th eir perform an ce reached a plateau . They were arranged to have a multi-disciplinary a s s e s s m e n t s i x m o n t h s a f t er d i s c h a r g e. P h y s io t h e r a p i s t , o c cu p a t i on a l t h e r a p is t a n d n u r s e u s e d t h e F u n c t io n a l In d e p e n d e n c e Me a s u r e (FIM) 7 t o m e a s u r e t h e i r fu n c t io n a t a d m is s i on , discharge and six mon ths p ost-discha rge. The stu dy institu tion par ticipa ted in th e Uniform Da ta S ervice for Medical Reha bilitation, a n d its s ta ff h ad received t h e r e q u i r e d t r a in i n g t o en s u r e t h e p r o p e r u s e o f   FIM. Th e FIM score was developed as a m easu re of  a p e r s o n ’s d i s a b i li t y a n d o f t h e p r o g r e s s m a d e i n t h e r e h a b i li t a t io n p r o gr a m , a n d i t s v a li d it y a n d r e l ia b i l it y h a d b e e n d o c u m e n t e d p r e vi ou s l y. Th e FIM score is a com posite of six su bsections dealing w it h s e l f- c a r e , m o b i l it y , s p h i n c t e r , l o c om o t i o n , communication and social cognition. The score for e a c h i t em w a s a d d e d t o m a k e t h e s u b s e t s c o r es , a n d t h e s e w e r e a d d e d fo r t h e t o t a l F IM s c o r e . F IM was chosen becau se it is m ore sensitive to cha nges. In c om p a r is o n , o t h e r a s s e s s m e n t t o o l s u c h a s B a r t h r e l In d e x wa s k n o wn t o h a ve m a r k e d f lo or i n g and ceiling effect. Data were analysed by statistic computer software, SPSS (version 7.5). Descriptive st at istics w er e u s e d t o s u m m a r i s e d a t a . B e t we en - g r ou p c o m p a r i s o n s w e r e m a d e w it h t h e s t u d e n t ’s t t e s t o r AN OVA fo r c o n t i n u o u s v a r i a b l e s . P a i r e d t t e s t w a s u s e d t o a n a l ys e p a ir e d d a t a . C o r r e la t i on w a s c a l cu la t e d a c c or d i n g t o S p e a r m a n r a n k c o r r e la t i on method. Tests were two-tailed, with results c o n s i d e r e d s i gn i fi ca n t a t P < 0 . 0 5 . Results

63 elderly patients were recruited during the 2 0 - m o n t h p e r io d . 5 2 p a t ie n t s h a d a s ix m o n t h s p o s t - d i s c h a r g e fo ll ow - u p a s s e s s m e n t w h i le 1 1 pa tients defau lted. Two of th e pat ien ts s u ffered from another episode of stroke within the six-month period after their discharge from GDH and were

Table 1: Characteristics in subjects & defaulters 

Subject (N=50) 76.1 7.7 3.3

Defaulter (N=11) 78.6 8.3 2.7

12.8 22.8

12.0 19.5

0.25 0.43 0.17 0.62 0.28

Mean total FIM score (admission)

85.2

78.7

0.42

Mean total FIM score (discharge)

93.1

90.0

0.69

Mean difference in total FIM score (between admission & discharge)

7.9

11.3

0.27

Age AMT score No. of diagnosis Length of stay (weeks) No. of attendance

P value

e x cl u d e d f r o m t h e d a t a a n a l ys i s . Th e r e f or e a t o t a l of 50 subjects were analysed. There were no significant statistical difference between the 50 su bjects a n d th e defau lters in th eir a ge, AMT score, n u m b e r o f m e d i c a l d i a gn o s e s a n d d u r a t i on o f d a y hospital rehabilitation training. Their FIM scores u p o n a d m i s s i on a n d d is c h a r g e fr o m G D H w e r e a ls o of no s ign ifican t s ta tistical differen ce. (Table 1) Am o n g 5 0 s u b j e ct s , 1 7 o f t h e m w e r e fe m a l e w h i le 3 3 w e r e m a l e . Th e m e a n a g e o f t h e s u b j e ct s w a s 7 6 . 1 ± 1 ( S E M ) w it h a r a n g e o f 6 5 t o 9 0 . Th e i r m e a n a n d m e d i a n AMT s c o r e wa s 7 . 7 ± 0 . 3 a n d 8 respectively. Their mean number of medical diagnoses was 3.3 diagnoses per patient. The med ian length of sta y (LOS) in da y hospita l was 12 w ee k s (r a n g e 5 - 3 0 ). Th e i r m e a n t o t a l n u m b e r o f   a t t e n d a n c e w a s 2 2 . 8 (r a n g e 7 - 5 6 ). H a l f o f t h e subjects were living in an institutional care setting (either private old age home or government su bvented ca re an d atten tion h ome), while the oth er 2 5 s u b j e ct s w e r e l ivi n g a t h o m e . The total FIM scores upon admission and dischar ge were 85.2 ± 3 . 2 a n d 9 3 . 1 ± 3.1 resp ectively. The tot al FIM scores a t d isch ar ge were significan tly higher tha n t ha t of u pon a dm ission (p<0.001). There was a gain of 8.5 ±1.2 in the total score. The gain in

Table 2: Differences according to AMT scoring subgroup 

Age No. of diagnosis Length of stay (week) No. of attendance Mean total FIM score (admission) Mean total FIM score (discharge) Mean total FIM score (6 months post-discharge) Difference in total FIM score (between admission & discharge) Difference in total FIM score (between discharge & 6 months post-discharge)

AMT ≤6 (N = 15) 74.7 3.07 13.7 23.6 75.9 85.7 82.2 9.9 -3.5

AMT >6 ( N = 32) 76.0 3.41 12.7 23.1 92.7 99.8 99.9 7.1 0

P value 0.54 0.41 0.56 0.86 0.005 0.016 0.009 0.35 0.18

29

Journal of the Hong Kong Geriatrics Society • Vol. 11 N o.1 Jan. 2 00 2 

FIM score was p ositively correlated with th e nu m ber of att en da n ce (r = 0.49, p<0.001 ) (Figu re 1), length of  stay (r = 0.42, p= 0.002) (Figu re 2) an d n egat ively with FIM score u pon a dm ission (r = -0.38, p = 0.006) (Figu re 3). However, th ere was n o sta tistic correlation between gain in th e total FIM score an d age, gen der, AMT score or n u m ber of m edical diagn osis. Mean FIM score at the six-month post-discha rge follow-up a ssess men t was 91 .7 ±3.5. When comp ared to th e FIM score on d ischar ge, th ere was a drop of 1. 4 ±1 . 1 i n t o t a l F I M s c o r e b u t w a s o f n o s t a t i s t i c a l significan ce (p = 0.5 9). Th e ch an ge of tota l FIM score an d its su bsets at six-mon th post-discharge was not correlated with age, gender, number of attendance, n u m b e r o f m e d i c a l d i a g n o s e s a n d l iv in g environm ent (staying at hom e or ins titutional care). However, th e ch an ge in t otal FIM score a t th e followu p a ssessm ent correlated p ositively with the ch an ge in the total FIM score between admission and disch ar ge (r = 0.2 9, p = 0.04) (Figu re 4 ). Concerning cognition, the subjects were su bdivided int o two group s a ccording to their AMT score (≤6 a n d >6). Th ere were sta tistical significan t difference in the mean total FIM score upon admission and discharge (Table 2). Nevertheless,

t h e g r ou p w i t h l o we r AM T s c o r e h a d a c o m p a r a b l e g a in i n t h e t o t a l F IM s c o r e a ft e r t h e r e h a b i lit a t i on p r o g r a m (i .e . t h e d i ffe r e n c e i n t h e t o t a l F IM s c o r e b e t we e n a d m i s s i on a n d d is c h a r g e), t h o u g h w it h a s i m ila r l e n g t h o f s t a y o r n u m b e r o f a t t e n d a n c e a s c o m p a r e d t o t h e g r o u p w it h h i g h e r AM T s c o r e . At t h e s i x m o n t h s p o s t - d is c h a r g e a s s e s s m e n t , subject with a lower AMT score (≤6 ) d i d n o t s h o w an y stat istical differen ce in t erm of cha n ge of total FIM score from th e time of discha rge to six mon th s a f t e r t h e c o m p l e t io n o f t h e r e h a b i li t a t i on p r o g r a m in GDH as compared to their counterpart. When t h e F IM s c or e s w e r e a n a l y s e d a c c o r d i n g t o t h e i r s u b s e t s , t h e r e w a s a s t a t is t i c a lly s i gn i fi ca n t d r o p Table 3: Difference in FIM score (between discharge & 6 months  post-discharge) in different subsets 

Communication Locomotion Mobility Self-care Social cognition Sphincter control

ni

ni MI

MI

AMT >6 ( N = 32) 0 -0.2 0.3 0.5 -0.1 -0.4

P value

0.33 0.36 0.03 0.08 0.1 0.88

a a g g F F

FIM score on admission to GDH 

Number of attendance 

Figure 1 Correlation between FIM gain and number of  attendance (r=0.85, p<0.01)

Figure 3 Correlation between FIM gain and initial FIM score (r=-0.38, p=0.006)

e g n 6 a h MI c F is f d

in o

t

a

s s

g

o e g

p

MI n

s a

F

ht h C

Duration of stay at GDH (weeks)

Figure 2 Correlation between FIM gain and duration of stay at GDH (r=0.42, p=0.02) 30

AMT ≤6 (N = 15) -0.5 -0.7 -1.1 -0.8 -0.7 -0.3

n o m

FIM gain during rehabilitation 

Figure 4. Correlation between changes of FIM 6 months post discharge and initial FIM gain during rehabilitation (r=0.29, p=0.04)

KW Lee et al • Stroke Rehabili tation and G DH 

Figure 5. Change of total FIM based according to AMT groups.

in th e score in th eir m obility su bset for patient with lower AMT score (Table 3). At t h e s i x m o n t h s p o s t - d is c h a r g e a s s e s s m e n t , subject with a lower AMT score (<6) did not show an y stat istical differen ce in t erm of cha n ge of total FIM score from th e time of discha rge to six mon th s a f t e r t h e c o m p l e t io n o f t h e r e h a b i li t a t i on p r o g r a m in GDH as compared to their coun terpart (Figure 5). Wh e n t h e F IM s c o r e s w e r e a n a ly s e d a c c o r d in g t o t h e i r s u b s e t s , t h e r e w a s a s t a t i s t i c a l l y s i g n i f i c a nt drop in th e score in th eir m obility su bset for pa tient with lower AMT score (Table 3 ). Discussion

In this prosp ective stu dy, we ha ve demon stra ted that elderly stroke patients improved in their fu n c t i o n a l i n d e p e n d e n c e a f t e r r e h a b i li t a t io n i n a geriatr ic day hosp ital setting. More importa nt ly, th e g a i n i n fu n c t i o n a l in d e p e n d e n c e c o u l d b e m a i n t a in e d s i x m o n t h s a f t e r t h e c om p le t io n o f t h e rehabilitation program. O n e m a y a r gu e t h a t t h e ga i n i n t h e fu n c t i on a l independence during and six months after the r e h a b i lit a t i o n p r o g r a m m a y ju s t r e fle c t t h e n a t u r a l cours e of the d iseas e in the ea rly post s troke period. It i s w e ll k n o w n t h a t n e u r o l og ic a l a n d fu n c t i o n a l recovery is most rap id in the first 3 m onth s, thou gh s o m e p a t i e n t s c o n t i n u e t o p r o g r es s b e y o n d t h a t t i m e . Aft e r 6 m o n t h s fr o m t h e a c u t e e ve n t , m o s t patients would be considered to have passed the p o in t t h a t a n y s p o n t a n e o u s n e u r a l r e c o ve r y w ou ld o c cu r . H o we ve r , a s a w h o le g r ou p , t h e n a t u r a l history of recovery from stroke after 3 months is m i x e d w i t h s o m e p a t i en t s i m p r o vi n g , s o m e r e m a in i n g s t a b l e a n d s o m e d e m o n s t r a t in g fu n c t i o n a l d e c li n e . D o m b o vy e t a l 8 , d e m o n s t r a t e d t h a t w it h o u t o u t p a t i e n t t h e r a p y t h e r e w a s improvement in functional status in only 22% of  p a t i e n t s , w h i le t h e o t h e r w o u l d e it h e r r e m a i n e d n o cha nge or sh owed fu nctional deterioration. Davidoff  e t a l 9 also foun d th ose patients who did not receive ph ysical an d occup ational th erapy in th e post-acute

p e r io d r e m a i n e d u n c h a n g e d a t 1 2 - m o n t h fo llo w u p . F u r t h e r m o r e, S m i t h e t a l 1 0 s h o w ed t h a t t h o s e s t r o k e s u r v iv or s w h o d i d n o t r e c e iv e a n y t h e r a p y s h o we d a s u b s t a n t i a l d ec r e m e n t i n t h e ir fu n c t i on a l c a p a c it y a t 1 2 - m o n t h p o s t - d is c h a r g e . F a c t o r s t h a t m a y a s s o c ia t e w it h t h e g a i n o f   fu n c t i o n a l in d e p e n d e n c e d u r i n g t h e r e h a b i li t a t i on p r o gr a m o r t h e m a i n t e n a n c e o f s u c h i m p r o ve m e n t were looked into in this study. Longer period of  t r a i n i n g in t e r m o f l on g e r le n g t h o f s t a y or m o r e n u m b e r o f a t t e n d a n c e we r e a s s o c i a t e d wi t h la r g e r gain in th e FIM score. The gain in FIM score du ring th e program was n egatively correlated with th e FIM score on adm ission, which m ay be du e to the ceiling e ffe c t o f t h e m e a s u r e m e n t . H o we ve r , a s n o t e d b y o t h e r i n v e s t ig a t o r s , s u b a c u t e s t r o k e r e h a b i li t a t io n p r o g r a m m a y b e n e fi t m o s t fo r p a t ie n t s w it h m o d e r a t e o r s e ve r e s t r o k e 1 1 . Ag e , ge n d e r a n d nu mb er of med ical diagnosis did not a ffect th e gain in t h e t o t a l F IM s c o r e in t h is s t u d y . F a c t o r s t h a t m a y a ffe c t t h e m a in t e n a n c e of t h e fu n c t i on a l in d e p e n d e n c e i n s t r o k e p a t i e n t a ft e r t h e r e h a b i lit a t i on t r a i n i n g is a n o t h e r im p o r t a n t a r e a t o be explored. Chan ges in tota l FIM score at 6 m onth s after discharge from the GDH was shown to be positively correlated with th e cha n ge of th e score right a f t e r t h e c o m p l e t io n o f t h e r e h a b i li t a t i on i n G D H . Therefore, patients who had improved in the reha bilitation program would likely to mainta in th eir fu n c t i o n a l i n d e p e n d e n c e s i x m o n t h s l a t e r . Ag e, g en d e r a n d n u m b e r o f m e d i c a l d ia g n o s i s d i d n o t relate to the cha nge in th e fu nctional ind ependen ce in o u r s t u d y . Mo r e ove r , m o r e G D H a t t e n d a n c e d id not appear to facilitate the maintenance of the fu nct ion al stat e. Th ere is a b elief th at ins titu tion alised elderly would deteriorate significantly after the termination of the reh ab ilitation tr aining. However, we were unable to demonstrate any statistical d e t e r i or a t i o n i n t o t a l F IM s c o r e or i t s s u b s e t s . Cognitive im pairm ent h as been rep orted to be a lim itin g factor for fu n ction al gain in p at ien ts r eceivin g r e h a b i li t a t io n . H o w e ve r , D i a m o n d e t a l 1 2 h a d d e m o n s t r a t e d t h a t i n a n i n p a t i e n t e l d e r ly rehabilitation setting those patients with cognitive imp airmen t sh owed a similar increase in fu nctional s t a t u s a s m e a s u r e d b y F IM. In o u r s t u d y , we w er e also able to demon stra te a similar degree of gain in tota l FIM score in p at ients with lower AMT score (≤6 ) as comp are to th ose with h igher AMT score (>6) in a day hospital setting. This functional gain was achieved with a s imilar length of stay and nu mb er of  s e s s i on a t t e n d e d . As n o t ed t h e y m a y h a v e m o r e difficu lty in ma intaining m obility at 6 mon th s. Yet, total FIM score at six months post-discharge as ma inta ined an d was also compara ble between th ese 31

Journal of the Hong Kong Geriatrics Society • Vol. 11 N o.1 Jan. 2 00 2 

two group s of pat ient s. We cons idered that tr eatm ent pr ovided t o a grou p of patien ts with lower AMT score would still resu lt in a s ign ifican t gain in fun ction al independ ence. Moreover, th is fu nctional gain was n ot a t r a n s i e n t o n e . Th e r e f or e , c o gn i t i ve i m p a ir m e n t sh ould n ot be a n exclu sion criterion for the p rovision of rehabilitation training. In t h is s t u d y , t h e s u b je ct s h a d d e m o n s t r a t e d a s t a t i s t i c a l s i gn i fi ca n t g a i n o f fu n c t i on a l a b i l it y a s m e a s u r e d b y t h e F u n c t io n a l In d e p e n d e n c e Me a s u r e (F I M). G r a n g e r e t a l 1 3 h a d d e m on s t r a t e d t h a t g a in i n g o n e p o i n t o n t h e t o t a l F I M s c o r e w o u l d translated into a reduction of attendant care of  app roxima tely 2.2 min p er day. Therefore, a cha nge of 8.5 in t he t otal FIM score in ou r group of patients will tran slate int o saving 18.6 min of attenda nt care per day. More importantly, this gain in the fu n c t i on a l in d e p e n d e n c e c o u l d b e m a i n t a i n e d s i x months after the patients being discharge from g e r ia t r i c d a y h o s p i t a l. Th i s w o u l d b e p a r t i c u l a r l y important in an institutional setting where one atten da nt m ay be looking after a nu mb er of elderly. However, our stu dy was n ot with out limitations. Firstly, our s am ple size was s m all. Th is limited the power of the study to detect any clinical relevant difference th at m ight exist, in pa rticular du ring the s u b g r o u p a n a l ys i s . N ev er t h e le s s , 6 3 e ld e r l y w it h a n a v e r a g e le n g t h o f s t a y o f 1 2 w e e k s a c c ou n t e d fo r a b o u t a t h i r d of t h e o c c u p a n c y w it h i n t h e s t u d y p e r i od i n t h e G D H wi t h a t o t a l o f 2 5 p l a c e m e n t s . Th e r e fo r e , a m u l t i- c e n t r e s t u d y w it h a l a r ge r n u m ber of pa tients will be des irable. Stra tificat ion o f t h e s u b j e c t s w i t h d i ffe r e n t s i t e o f t h e l e s io n o r different fun ctiona l problem m ay th en b e also done. Secondly, the result was subjected to bias b e c a u s e o f t h e d e fa u l t er s (1 7 % d e fa u l t r a t e ). Th e y might be a group of patients who performed poorly a n d u n a b l e t o r e t u r n fo r fo ll ow u p s i x m o n t h a f t er discharge because of significant functional deterioration. However, as dem onst rat ed earlier the d e fa u l t er s h a d c o m p a r a b le b a s e li n e c h a r a c t e r is t i cs with the other 50 patients and there was no objective eviden ce th at t h ey were ou tliers. I n c o n c l u s i on , G D H i s a n e ffe c t i ve s e t t i n g fo r e ld e r l y s t r o k e p a t ie n t s a n d t h e fu n c t i on a l ga i n c a n b e m a i n t a in e d a t s ix m o n t h s p o s t -d is c h a r g e .

Rehabilitation outcome is correlated positively with length of stay and total number of attendance of  GDH, and negatively with initial FIM score. Cognitive impairment and institutionalisation should not be a hindrance to the access of this p a r t i c u l a r r e h a b i li t a t i on s e r v ic e . H o we ve r , a c on t r o l le d s t u d y w it h a l a r g e r s a m p l e s h o u l d b e performed to validate the observations and the h y p o t h e s e s fo r m u la t e d fr o m t h e p r e s e n t s t u d y , a n d to provide ins igh t in t he effectivenes s of the p rogram a n d fa c t o r s i n r e l a t io n t o t h e m a i n t e n a n c e of t h e fu n c t i o n a l s t a t u s i n a m o r e u n e q u i vo c a l w a y .  References: 1. Brocklehurst JC, Tucker JS. Progress in Geriatric Day Care. King Edward’s Hospital Fund for London, London, 1980. 2. Leung EMF, Ng YY. Geriatric day hospital in Hong Kong: a threeyear follow-up study.  Age & Ageing 1984; 13:282-4. 3. Young JB, Forster A. The Bradford community stroke trial: results at six months.  Br Med J 1992; 304:1085-9. 4. Gladman JRF, Lincoln NB, Barer DH. A randomised controlled trial of domiciliary and hospital-based rehabilitation for stroke patients after discharge from hospital.   J Neurol Neurosurg Psychiatry 1993; 56:960-6. 5. Hui E, Lum CM, Woo J, Or KH, Kay RLC. Outcomes of elderly stroke patients: Day hospital versus conventional medical management. Stroke 1995; 26:1616-9. 6. Garraway WM, Akhtar AJ, Hockey L, Prescott RJ. Management of acute stroke in the elderly: follow-up of a controlled trial.  Br   Med J 1980; 281:827-9. 7. Guide for Uniform Data Set for Medical Rehabilitation; version 4.0 (Adult FIM). Baffalo (N.Y.). University of Baffalo Foundation Activities: 1993 8. Dombovy ML, Basford JR, Whisnant JP, Bergstralh EJ. Disability and use of rehabilitation services following stroke in Rochester, Minnesota, 1975-1979. Stroke 1987; 18:30-6. 9. Davidoff G, Keren O, Ring H, Solzi P. Long-term effects of  rehabilitation and maintenance of gains.  Arch Phys Med Rehabil 1991; 72:869-73. 10. Smith DS, Goldenberg E, Ashburn A et al. Remedial therapy after stroke: a randomised controlled trial.  Br Med J 1981; 282:517-20. 11. Ronning OM, Guldvog B. Outcome of subacute stroke rehabilitation: a randomized controlled trial. Stroke 1998; 29:779-84. 12. Diamond PT, Felsenthal G, Macciocchi SN, Butler DH, LallyCassady D. Effect of cognitive impairment on rehabilitation outcome.  Am J Phys Med Rehabil 1996; 75:40-3. 13. Granger CV, Cotter AC, Hamilton BB, Fiedler RC. Functional assessment scales: a study of persons after stroke.  Arch Phys Med   Rehabil 1993; 74:133-8.

 LEARNING POINTS 1 . GDH i s a n e f fe c t i ve s e t t i n g f or r eh a b i l i t a t i o n o f e l d e r ly s t r o k e p a t i e n t . Th e f u n ct i o n a l   i m p r o v em e n t c a n b e m a i n t a i n e d a t 6 m o n t h s p o s t d i s c h a r g e f r om G DH. 2 . R eh a b i l i t a t i o n o u t c om e i s p o s i t i v e ly c o r re l a t e d w i t h i n i t i a l FIM s c o re , le n g t h o f s t a y a n d t o t a l n u m b e r o f a t t e n d a n c e a t G DH. 3 . T h e re is n o s t a t i s t i c a l d i f fe r e nc e in t h e fu n c t i o n a l g a i n a m o n g c o gn i t i ve l y im p a i r ed   (AMT  ≤ 6 ) p a t i e n t s w h e n c o m p a r e d w i t h c o g n i t i v e l y s o u n d (AMT >6 ) p a t i e n t s . W i t h t h e e x c ep t i o n o f m o b il i t y , f un c t i o n a l o u t c om e i s m a i n t a i n e d a t 6 m o n t h s a m o n g c o g n it i v e ly i m p a i r ed p a t i e n t s . 32