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Systematic Review

Outcome measures for older adults in rehabilitation wards: a systematic review

[version 1; peer review: awaiting peer review]
Shota Suzumura
https://orcid.org/0000-0001-7346-9326
1,2, Eiko Takano3, Toshio Teranishi1, [...] Kei Ito4, Hiroaki Sakurai1, Yoshikiyo Kanada1, Izumi Kondo2,3
Shota Suzumura
https://orcid.org/0000-0001-7346-9326
1,2, Eiko Takano3, [...] Toshio Teranishi1, Kei Ito4, Hiroaki Sakurai1, Yoshikiyo Kanada1, Izumi Kondo2,3
PUBLISHED 03 Oct 2024
Author details Author details
OPEN PEER REVIEW
REVIEWER STATUS AWAITING PEER REVIEW

Abstract

Purpose

Detailed reports of the assessments used in rehabilitation wards are lacking. This study aimed to examine the common evaluations used in rehabilitation wards and discuss the necessary assessments for treatment plans and patient management.

Methods

We conducted a comprehensive literature search of PubMed, Web of Science, MEDLINE, and Ichushi Web for articles published between June 2013 and June 2023. The study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered with PROSPERO. Data extraction and blind selection were performed, and a consensus was reached among experts in case of conflicts.

Results

We identified 220 studies, 31 meeting the inclusion criteria post-screening. The Functional Independence Measure was the most used assessment (96.8%), followed by grip strength (32.3%) and the 10-m walk test (9.7%). Other assessments included the Stroke Impairment Assessment Set, Short Physical Performance Battery, and Timed Up and Go Test. Although fall-related incidents are frequent, significantly affecting patient outcomes in rehabilitation units, balance assessments were underutilized.

Conclusions

Although the FIM is an extensively used assessment in rehabilitation wards, balance assessments critical for fall prevention are significantly underused. Therefore, these assessment tools should be evaluated in future research and clinical practice.

Keywords

outcome measures, falls, Functional Independence Measure, rehabilitation, older adults

Corresponding author: Eiko Takano
Competing interests: No competing interests were disclosed.
Grant information: The author(s) declared that no grants were involved in supporting this work.
Copyright:  © 2024 Suzumura S et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
How to cite: Suzumura S, Takano E, Teranishi T et al. Outcome measures for older adults in rehabilitation wards: a systematic review [version 1; peer review: awaiting peer review]. F1000Research 2024, 13:1120 (https://doi.org/10.12688/f1000research.155302.1) First published: 03 Oct 2024, 13:1120 (https://doi.org/10.12688/f1000research.155302.1) Latest published: 03 Oct 2024, 13:1120 (https://doi.org/10.12688/f1000research.155302.1)

Introduction

In the rehabilitation of older adults, prompt improvement in activities of daily living (ADLs) during recovery from illness or surgery is essential. ADLs include basic activities of daily living such as eating, bathing, dressing, and toileting; the ability to independently perform these activities can improve the quality of life (QOL) of older adults. ADLs are closely related to QOL1–5 and social participation6–9 and are fundamental in older adults leading safer and more fulfilling lives at home and in the society. In addition, this foundation helps maintain social connections, prevent isolation, and provide spiritual satisfaction.

Improving ADLs requires a treatment plan that includes optimized patient management based on assessments of the patient’s physical functions and activity levels. Adequate assessment in the early stages of rehabilitation is essential to prevent safety-related adverse events,10 which frequently occur in rehabilitation wards, and establish a foundation of independent living for older adults. After an appropriate patient assessment, an optimal treatment plan can be designed and implemented. Meanwhile, inadequate assessments and incorrect treatment plans may not only impede patient recovery but also increase the risk of safety-related adverse events in rehabilitation wards.

However, detailed reports of the assessments used in rehabilitation wards are lacking. Assessment methods used in rehabilitation wards comprise physical function assessments, psychological function assessments, and assessments of social factors. Physical function assessments include muscle testing, neurological testing, and balance assessment. Moreover, cognitive and psychosocial assessments are essential for successful rehabilitation. These assessment methods are critical to the success of a rehabilitation program; therefore, evaluating their effectiveness and deriving specific remedial measures are essential.

Therefore, the present study aimed to review the assessments commonly used in rehabilitation wards and discuss the assessments required for the development of treatment plans, including patient management. Through this review, we aimed to contribute to the optimization of assessments used in the rehabilitation of older adults.

Methods

Literature search and study selection

The methodology employed in this systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.11 This systematic review was registered in the PROSPERO International Prospective Register of Systematic Reviews (registration number: CRD42023393290). The PRISMA checklist for this report of the review is available in Extended Dataset: Appendix 1.12 This systematic review of the literature was conducted in July 2023. The data were collected from PubMed, Web of Science, MEDLINE, and Ichushi Web, a Japanese journal database; we reviewed articles published in the last 10 years (June 2013 to June 2023) to obtain the latest evidence. The inclusion criteria were as follows: (1) the study included patients admitted to a convalescent or rehabilitation ward; (2) the study included older adults aged 65 years or older; and (3) the paper was published in English or Japanese. Studies were excluded if they met the following criteria: (1) inclusion of a non-standard assessment; (2) wrong population such as genetic, rat, or community-dwelling older adults; (3) abstracts, letters, editorials, protocols, proceedings, expert opinions, reviews, and case reports; 4) studies of Acute, Chronic, Community-Based, and Post-Discharge Rehabilitation. Furthermore, this review focused on papers that assessed physical and daily functioning, rather than physiological, severity evaluation, nutritional, swallowing, or cognitive assessments.

The search was performed using the following keywords: (“Older patients” OR “elderly patients” OR “geriatric patients” OR “senior patients” OR “aged 65 years or over” OR “65 years and older”) AND (“Rehabilitation Hospital” OR “RH ward” OR “Rehabilitation ward” OR “Rehab ward” OR “RH unit” OR “Rehabilitation unit” OR “Rehab unit”) AND (“Activity” OR “activity level” OR “activity measures” OR “functional activity”) (Table 1).

Table 1. Keywords used for the search strategy.

1“Older patients” OR “elderly patients” OR “geriatric patients” OR “senior patients” OR “aged 65 years or over” OR “65 years and older”
2“Rehabilitation Hospital” OR “RH ward” OR “Rehabilitation ward” OR “Rehab ward” OR “RH unit” OR “Rehabilitation unit” OR “Rehab unit”
31 AND 2
4“Activity” OR “activity level” OR “activity measures” OR “functional activity”
53 AND 4

All references from the initial search were exported to Rayyan software for data extraction. After the removal of duplicates, the first and second authors of the present study performed a blinded selection of literature according to the inclusion and exclusion criteria. The initial screening was based on the titles and abstracts of the identified articles. Subsequently, the same experts evaluated the full text of selected papers. In the case of conflicting opinions, a consensus was reached through discussion among the three experts.

Results

The initial comprehensive search of PubMed, Web of Science, MEDLINE, and Ichushi Web databases produced 220 articles. After the removal of duplicate articles, 206 articles were selected. A thorough screening of the titles and abstracts led to the exclusion of 169 articles. Afterward, the full texts of the remaining 37 articles underwent a meticulous review. Ultimately, after thorough analysis, 31 articles were deemed appropriate for data extraction and,13–43 thus, included in the review (Extended Dataset: appendix 2).12

The detailed results of the review are shown in Tables 2 and 3. The Functional Independence Measure (FIM) was the most frequently used outcome measure for inpatients in the rehabilitation ward (n = 30, 96.8%).13–42 The FIM is a widely used tool for evaluating ADLs.44 Other commonly used evaluations in rehabilitation wards include grip strength (n = 10, 32.3%),27,13,16,18,19,22,23,29,41,43 the 10-meter walk test (10MWT; n = 3, 9.7%),16,29,41 the Stroke Impairment Assessment Set (SIAS; n = 2, 6.5%),26,38 the Short Physical Performance Battery Test (SPPB; n = 2, 6.5%),29,43 the Brunnstrom stage test (BRS-t; n = 1, 3.2%),19 the Functional Ambulation Categories (FAC; n = 1, 3.2%),24 the 30-second chair stand test (CS-30; n = 1, 3.2%),16 the Katz Index of Independence in Activities of Daily Living (Katz Index of Independence in ADL, n = 1, 3.2%),43 the Lawton Instrumental Activities of Daily Living scale (Lawton IADL scale; n = 1, 3.2%),43 the Timed Up and Go Test (TUG; n = 1, 3.2%),43 and the Frail 10-second Chair Stand Test for Frail Elderly (Frail CS-10; n = 1, 3.2%).42

Table 2. Descriptive analyses of the 31 studies included in the present review.

AuthorSpecific objectiveYearParticipantsSettingEvaluation
Abe et al.12To assess the nutritional status of patients in the recovery ward and examine the characteristics of undernourished patients202094 older adult patients aged 65 years or olderRehabilitation ward

  • • FIM

  • • Grip strength

Aoki et al.13To identify factors influencing the discharge destination of stroke patients in the rehabilitation ward2019103 older adult patients with stroke aged 65 years or olderRehabilitation ward

  • • FIM

Brown et al.14To investigate the association between the number of days of hospitalization from the onset of stroke to admission in the rehabilitation ward, nutritional status, and ADL recovery in patients with stroke202189 older adult patients with stroke aged 65 years or olderRehabilitation ward

  • • FIM

Fujii et al.15To examine whether BCAA-fortified dietary supplements are effective in improving ADLs and the rehabilitative effects may be expected201914 older adult patients with stroke aged 65 years or older (the intervention or control group)Rehabilitation ward

  • • FIM

  • • 10MWT

  • • CS-30

  • • Grip strength

Hanaoka et al.16To investigate the relationship between H2RA use and FIM gain, which determines the rehabilitation outcomes for patients admitted to rehabilitation wards2020236 older adult patients aged 65 years or older [H2RA (-), H2RA (+) group]Rehabilitation ward

  • • FIM

Iwase et al.17To identify factors associated with home discharge in older adult patients with femoral fractures201766 older adult patients aged 85 years or older with a femoral fracture (discharged home or to a non-home group)Rehabilitation ward

  • • FIM

  • • Grip strength

Kameyama et al.18To determine whether sarcopenia affects ADLs in older adult patients with stroke2022283 older adult patients with stroke aged 65 years or olderRehabilitation ward

  • • FIM

  • • Grip strength

  • • BRS-t

Kose et al.19To examine the effect of PIM on rehabilitation outcomes in geriatric patients after stroke2018272 older adult patients with stroke aged 65 years or olderRehabilitation ward

  • • FIM

Kose et al.20To examine the effect of deprescribing from polypharmacy on ADL recovery and home discharge by rehabilitation in older patients with sarcopenia after stroke2023153 older adult patients aged 65 years or older diagnosed with sarcopenia with polypharmacyRehabilitation ward

  • • FIM

Kubo et al.21To identify factors associated with ADL ability in older adult orthopedic patients with comorbid cognitive impairment and depression2021104 older adult patients aged 65 years or older with orthopedic diseases (no cognitive impairment and no depression, no cognitive impairment and depression, cognitive impairment and no depression, cognitive impairment, and depression groups)Rehabilitation ward

  • • FIM

  • • Grip strength

Matsumoto et al.22To investigate the association between polypharmacy at hospital discharge and nutritional intake, muscle strength, and ADLs among older patients undergoing rehabilitation after stroke2022179 older adult patients with stroke aged 65 years or olderRehabilitation ward

  • • FIM

  • • Grip strength

Miura et al.23To assess ADLs and the gait ability of patients with a PFF who had frailty before hospital admission202112 older adult patients aged 65 years or older (frail and no frail groups)Rehabilitation ward

  • • FIM

  • • FAC

Mizurahi et al.24To investigate whether, and to what extent, post-stroke eating management at admission to a rehabilitation ward is associated with functional outcome.2013716 older adult patients with stroke aged 65 years or older.Rehabilitation ward

  • • FIM

Murakami et al.25To investigate the relationship between improvement in ADLs and discharge to home among older stroke patients in a rehabilitation ward2020291 older adult patients aged 65 years or older with cerebral infarction (early-stage or late-stage older adult groups)Rehabilitation ward

  • • FIM

  • • SIAS

Nagao et al.26To investigate the prevalence of sarcopenia in patients with proximal femoral fractures who underwent surgery2018134 older adult patients aged 65 years or older with femoral fractures (sarcopenia or non-sarcopenia group)Rehabilitation ward

  • • FIM

  • • Grip strength

Nakamura.27To clarify risk factors for aspiration pneumonia and the effects of aspiration pneumonia on recovery after stroke in older adult patients with stroke in a rehabilitation ward.2020463 older adult patients with stroke aged 65 years or older who have dysphagiaRehabilitation ward

  • • FIM

Ohtsubo et al.28To assess the association of sarcopenia and physical activity with functional outcomes in older hospitalized rehabilitation patients2022211 older adult patients aged 65 years or older with musculoskeletal and neurological diseasesRehabilitation ward

  • • FIM

  • • SPPB

  • • 10MWT

  • • Grip strength

Otsubo et al.29To examine the relationship between cognitive dysfunction affecting motor FIM and hypnotics2022509 older adult patients aged 65 years or older with stroke, orthopedic disease, or disuse syndromeRehabilitation ward

  • • FIM

Sato30To identify predictive factors of home discharge in older adult patients with stroke hospitalized in our rehabilitation ward based on markers determined during hospitalization and to evaluate their predictive capability2020179 older adult patients with stroke aged 65 years or olderRehabilitation ward

  • • FIM

Sato et al.31To investigate the factors associated with undernutrition during admission in patients with cerebral infarction2022220 older adult patients with stroke aged 65 years or olderRehabilitation ward

  • • FIM

Sato et al.32To examine the association between undernutrition and performance index in patients with stroke2020108 older adult patients with stroke aged 65 years or olderRehabilitation ward

  • • FIM

Sato et al.33To investigate the association between the area of the psoas major muscle and prognosis in patients with cerebral infarction201955 older adult patients with stroke aged 65 years or olderRehabilitation ward

  • • FIM

Shimizu et al.34To determine the relationship between inadequate energy intake and change in physical activity at the start of recovery rehabilitation in hospitalized patients202242 older adult patients aged 65 years or older with orthopedic diseasesRehabilitation ward

  • • FIM

Shirosaki et al.35To examine the relationship between nutritional management and rehabilitation effectiveness in a rehabilitation ward201752 older adult patients aged 65 years or olderRehabilitation ward

  • • FIM

Takei et al.36To clarify the influence of cognitive function on ADL and improvement of ADL at admission and discharge in patients with late-onset musculoskeletal disease based on severity of illness202151 older adult patients aged 75 years or older with orthopedic diseases (cognitive function: normal, mildly impaired, moderately impaired, and severely impaired groups)Rehabilitation ward

  • • FIM

Takeuchi et al.37To examine the effect of early rehabilitation on patients with stroke based on FIM severity at admission2017312 older adult patients with stroke aged 65 years or olderRehabilitation ward

  • • FIM

  • • SIAS

Tokunaga et al.38To clarify the relationship between improvement in the GNRI and improvement in the FIM2016155 older adult patients with stroke aged 65 years or olderRehabilitation ward

  • • FIM

Umemoto et al.39To identify factors associated with the improved FIM scores from admission to discharge in TKA patients202225 older adult patients aged 65 years or older who underwent post-operative TKA (FIM improvement <12 points group or FIM improvement ≥12 points group)Rehabilitation ward

  • • FIM

Watanabe et al.40To investigate the rate of sarcopenia in a rehabilitation ward201829 older adult patients aged 65 years or older with orthopedic disease (sarcopenia group or non-sarcopenia group)Rehabilitation ward

  • • FIM

  • • 10MWT

  • • Grip strength

Yagi et al.41To clarify the impact of sarcopenia on the performance index of patients admitted to rehabilitation wards2022128 older adult patients aged 65 years or older with stroke, musculoskeletal disorder, or disuse syndromeRehabilitation ward

  • • FIM

  • • Frail chair standard-10

Zasadzka et al.42To analyze the impact of inpatient rehabilitation on the functional status of the older adults2016100 older adult patients aged 65 years or olderRehabilitation ward

  • • Katz Index of Independent in ADL

  • • Lawton IADL scale

  • • TUG

  • • SPPB

  • • Grip strength

Table 3. Outcome measures for older adults in rehabilitation wards.

Evaluation scalesNumber of articles
FIM30
Grip strength10
10MWT3
SIAS2
SPPB2
BRS-t1
FAC1
CS-301
Katz Index of Independent in ADL1
Lawton IADL scale1
TUG1
Frail CS-101

Extended Dataset: Appendix 312,81–117 presents commonly used evaluations for older adults in rehabilitation wards, along with information on their reliability and validity (construct validity and criterion-related validity). These evaluations include the FIM45 and Katz Index of Independent in ADL46 for ADL evaluation; the Lawton IADL Scale47 for IADL evaluation; the 10MWT,48 FAC,49 and TUG50 for the assessment of walking ability; grip strength, the CS-30,51 and the Frail CS-1052 for muscle strength evaluation; the SIAS53,54 for the assessment of the degree of paralysis; and the SPPB55 for the assessment of physical function.

Evaluation of ADLs and IADL

The FIM45 and Katz Index of Independent in ADL46 are foundational in assessing ADLs such as dressing, bathing, and eating. These tools are highly reliable and possess a strong construct validity, demonstrating their effectiveness in reflecting patients’ functional status. Similarly, the Lawton IADL Scale47 extends this assessment to more complex daily activities, including financial management and medication use, which are critical for independent living.

Evaluation of muscle strength

Grip strength is a targeted measure of muscle strength, which is a predictor of morbidity and mortality in older adults. In addition, the CS-3051 and Frail CS-1052 are simple but powerful predictors of overall health and functional decline; these tests are used in the evaluation of muscle strength.

Assessment of walking ability

The 10MWT48 measures walking speed over a short distance and is a quick indicator of mobility limitations. The FAC49 assesses the level of support required by a patient for walking, which is crucial for safety and independence. The TUG,50 combining the elements of balance, speed, and agility, is particularly valuable for predicting fall risk. These assessments help in developing individualized rehabilitation programs that improve mobility and reduce fall risk.

Assessment of paralysis and physical function

The SIAS53,54 and BRS-t56,57 provide a detailed measure of paralysis and are particularly useful in stroke rehabilitation. The SPPB55 is a comprehensive tool that assesses lower extremity function and is a predictive index of disability. It combines balance, gait ability, and strength evaluation.

Discussion

We conducted a systematic review of commonly used assessments in rehabilitation wards. The results showed that the FIM was the most frequently used assessment method, appearing in 30 (96.8%) of the 31 articles reviewed. Grip strength assessment was used in 10 articles (32.3%), and the 10MWT was mentioned in three articles (9.7%). These assessments are essential for developing an appropriate treatment plan for each patient.

Assessment plays an important role in rehabilitation treatment planning and in determining the effectiveness of interventions. Kirshner et al.58 categorized assessments into discriminative, predictive, and evaluative measures according to their specific use. Discriminative measures are used to determine the presence or absence of a disease, and predictive measures are used to predict treatment outcomes. Meanwhile, evaluative measures are used to assess an intervention’s effectiveness and for the adjustment of the treatment plan, as necessary. In rehabilitation, these outcome measures are used to identify specific problems, determine the effectiveness of interventions, assess risks, and determine a patient’s range of behavior. Thus, assessment in rehabilitation plays a multifaceted role and significantly contributes to patient recovery and QOL.

In rehabilitation wards, efforts focus on improving patients’ functions and abilities, thus extending the range of ADL, and establishing an appropriate range of activities for patients. Several studies have shown a positive association between physical activity levels and QOL. A systematic review found that higher physical activity levels were associated with better QOL across different populations, including older adults and those with clinical conditions.59,60 Meanwhile, an increased range of activities increases the risk of falls.61,62 Therefore, it is important to reduce the risk of falls, which are common in rehabilitation wards.10 Reported fall rates among hospitalized patients range from 1% to 17%.63–67 In particular, 36–73% of patients with stroke experience falls within 6 months of discharge,68–72 with 61% occurring in the first 2 months after discharge.73 Furthermore, falls are associated with the fear of falling, anxiety, and reduced ADLs; appropriate fall-related assessments are needed to reduce the risk of falls.74–77

However, our review revealed that balance assessment indices are rarely used in the evaluation of fall risks. Only two of the 31 articles (6.5%) used the SPPB, which includes balance assessment, and the TUG test was utilized in one article (3.2%). According to Ganz et al., a history of falls and abnormalities in gait and balance are significantly associated with the occurrence of falls. Conversely, visual impairment, administered drugs, reduced ADLs, and cognitive impairment are not good predictors of falls.78 Teranishi et al. reported a close association between static standing balance ability and falls, underscoring the importance of balance assessment for fall prevention.79 When the ability for ADLs reaches a plateau, training can improve balance ability.80 Therefore, balance assessments, in addition to ADL assessments, should be performed regularly and frequently; if otherwise, it will be challenging to prevent falls after a discharge from the hospital. Although preventing all fall events is difficult, the risk can be minimized via thorough assessment and intervention.

This study’s significant strength is that it provides the first comprehensive analysis of outcome measures widely used in rehabilitation wards. However, the study has several limitations. First, the literature reviewed was limited to English and Japanese, meaning essential studies in other languages may not have been included. Second, we only included studies on the outcome measures for patients in rehabilitation wards; therefore, data on the assessment methods used in other wards (e.g., acute or chronic) were not considered. Third, the present study lacks data to directly compare the effectiveness and efficacy of the assessment instruments. Therefore, future studies review a more diverse literature and examine the use of assessment tools in different healthcare settings.

This study systematically reviewed the status of assessment methods used in rehabilitation wards and confirmed that the FIM is the most widely used measure, particularly in rehabilitation settings. However, the use of critical assessment measures, such as balance assessments, was inadequate in the crucial aspect of fall prevention. Therefore, the active use of these assessment tools and verification of their effectiveness are required in future research and clinical practice. The results of the present study may contribute to further improving the quality of rehabilitation.

Author contributions

ET and IK: study concept and design. SS, ET, KI: acquisition of data (literature search and study selection). SS, ET, TT, HS, YK, and KI: analysis and interpretation of data (literature). SS, TT: writing—original draft preparation. ET, IK: supervision. SS, TT: writing—review and editing. All authors contributed to the article and approved the submitted version.

Data availability statement

Underlying data

Figshare. Outcome measures for older adults in rehabilitation wards: A systematic review. https://doi.org/10.6084/m9.figshare.26838841.v2 118

This study contains the following underlying data in the extended dataset:

  • • Data file Appendix 1. PRISMA checklist

  • • Data file Appendix 2. Flowchart of the search strategy

  • • Data file Appendix 3. The evaluations used for older adult in rehabilitation wards

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

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Suzumura S, Takano E, Teranishi T et al. Outcome measures for older adults in rehabilitation wards: a systematic review [version 1; peer review: awaiting peer review]. F1000Research 2024, 13:1120 (https://doi.org/10.12688/f1000research.155302.1)
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