Annals of Physical and Rehabilitation Medicine 63 (2020) 340–343

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Original article

Outcomes for older adults in inpatient specialist neurorehabilitation

Teng Cheng Khoo a,*, Alasdair FitzGerald a, Elizabeth MacDonald b, Lloyd Bradley c
a
Department of Neurorehabilitation, Astley Ainslie Hospital, Edinburgh, UK
b
Department of Medicine of the Elderly, Western General Hospital, Edinburgh, UK
c
Donald Wilson House Neurological Rehabilitation Centre, Western Sussex Hospitals NHS Trust, Chichester, UK

A R T I C L E I N F O A B S T R A C T

Article history: Background: Inpatient specialist neurorehabilitation in the United Kingdom is based on providing a
Received 16 January 2019 service to ‘‘working-age’’ adults (<65 years), with little evidence for outcomes for older adults involved
Accepted 1st May 2019 with these services.
Objective: The aim of this study is to determine any difference in outcome after inpatient
neurorehabilitation between younger and older adults assessed as having rehabilitation potential.
Keywords: Methods: A two-centre retrospective review was performed comparing patients aged < 65 and  65 years by
Neurorehabilitation diagnostic group in terms of length of stay, changes in UK Functional Independence Measure + Functional
Rehabilitation Assessment Measure (UK FIM + FAM) scores and discharge destination.
Rehabilitation potential Results: Six hundred and sixteen patients (32%  65 years) were included. The 2 age groups did not differ
Older adults
in length of stay (median difference 7 days, 95% confidence interval [CI] 2 to 15, P = 0.112), but both UK
UK FIM + FAM
FIM + FAM change and efficiency were higher for the older than younger group (median difference 7, 95%
CI 2–13, P = 0.006 and 0.10, 0.01–0.19, P = 0.031 respectively). Older age was associated with discharge
to long-term care (6% < 65 years; 11%  65 years, x2 = 4.10, P = 0.043). Results and trends were similar in
patients with acquired brain injury (n = 429), spinal cord injury (n = 59) and peripheral neuropathy
(n = 34) but not progressive neurological disorders (n = 70).
Conclusion: Older adults considered to have rehabilitation potential may have greater functional gains
from inpatient specialist inpatient rehabilitation than younger adults. Age alone should not exclude
admission to inpatient specialist neurorehabilitation.
Crown Copyright C 2019 Published by Elsevier Masson SAS. All rights reserved.

1. Introduction or geriatric services after an acute neurological illness may depend

Age over 65 years is widely accepted in developed countries as
the threshold defining an individual as an ‘‘older’’ adult [1] and is the
current retirement age in the United Kingdom [2]. There is good
evidence for the effectiveness of inpatient specialist neurorehabi-
litation in promoting long-term independence and reducing the cost
of long-term care after an acute neurological illness, but the evidence
is based solely on outcomes for ‘‘working-age’’ adults [3–5].
One of the admission criteria that neurorehabilitation units
may apply is limiting provision of a service to ‘‘working-age’’ adults
(<65 years) because of limited evidence of effectiveness in older
adults. Moreover, there may be an over-reliance on the assumption
that older adults have more co-morbidities and reduced potential
for improvement. Hence, referral patterns to neurorehabilitation
* Corresponding author. Charles Bell Pavilion, Astley Ainslie Hospital, 133,
Grange Loan, EH9 2HL Edinburgh, UK.
E-mail address: t.khoo@nhs.net (T.C. Khoo).
on an arbitrary age cutoff of 65 years, rather than considering
individual rehabilitation potential.
Several studies have suggested fewer functional gains in
neurorehabilitation by older vs. younger adults [6–8]. However,
these studies were based on arbitrary age cutoffs rather than
rehabilitation potential, and subgroups of older individuals are
known to engage in rehabilitation and have potentially better
outcomes [9–12]. Hence, the effectiveness and success of inpatient
specialist neurorehabilitation in older individuals is likely to be
closely related to appropriate patient selection.
With changes in life expectancy and the broader economy, the
idea of a universally defined limit to ‘‘working-age’’ is largely
redundant, as evidenced by the UK State Pension age being set to
increase to 67 years by 2028 [2]. The employment rate for people
aged  65 years has doubled over the past 30 years (from 5% to
10%) and will likely continue to increase [13]. Thus, expectations
for the provision of neurorehabilitation for older adults are likely to
increase.

https://doi.org/10.1016/j.rehab.2019.05.001
1877-0657/Crown Copyright
C 2019 Published by Elsevier Masson SAS. All rights reserved.
 T.C. Khoo et al. / Annals of Physical and Rehabilitation Medicine 63 (2020) 340–343
The aim of this study was to determine any difference in
outcomes between younger adults (<65 years) and older adults
(65 years) who have been assessed to have rehabilitation
potential and completed inpatient specialist neurorehabilitation.
This study also hoped to address the practical question of whether
the use of an arbitrary age cutoff is appropriate as an admission
policy for neurorehabilitation services.
2. Methods
2.1. Participants and settings
Patients admitted and completing their rehabilitation pro-
grammes at 2 geographically distinct inpatient specialist neuro-
rehabilitation units within the UK between January 2011 and
December 2016 were included in this retrospective study. There is
no absolute age limit in the admission criteria for the 2 units.
Patients referred are assessed individually for rehabilitation
potential. Factors taken into account during assessment include
pre-existing co-morbidities and pre-morbid functional and cogni-
tive status.
2.2. Inpatient rehabilitation outcomes
The outcomes assessed were length of stay (LOS), change in UK
Functional Independence Measure + Functional Assessment Measure
(UK FIM + FAM) and discharge destination. The UK FIM + FAM is a
validated 30-item inpatient global measure of disability and
functional independence that is responsive to functional changes in
a neurorehabilitation cohort [14]. UK FIM + FAM scores were collected
prospectively for each patient on admission and at discharge.
UK FIM + FAM change is defined as the absolute difference
between discharge and admission scores. UK FIM + FAM efficiency
is defined as UK FIM + FAM change divided by LOS. Discharge
destination is defined as either ‘‘home’’ or ‘‘long-term care’’ (LTC),
which includes residential or nursing homes.
Fig. 1. Length of stay (LOS) and UK Functional Independence Measure + Functional Assessment Measure (UK FIM + FAM) change and efficiency for younger (<65 years) and
older (65 years) age groups. Data are median (95% confidence intervals). The Mann-Whitney U test used to compare LOS.
341
2.3. Statistical analysis
Patients were classified by age (<65 and  65 years) and
diagnosis. Mann-Whitney U test or Student t test was used to
compare LOS and UK FIM + FAM scores between the 2 groups. Chi2
test was used to determine an association between discharge
destination and the age groups. Shapiro-Wilk test was used to test
for normality. All data were analysed by using SAS University
Edition. P < 0.05 was considered statistically significant.
2.4. Ethics approval
Unit 1 is part of the UK Rehabilitation Outcomes Collaborative
programme, which is a commissioning requirement for level 1 and
2 rehabilitation services in England [15]. Caldicott Guardian
approval was granted for Unit 2.
3. Results
Six hundred and sixteen patients were included in the study;
422 (68%) were < 65 years old (44% female; median age 52 years,
range 15–64) and 194 (32%) were  65 years old (51% female;
median age 69 years, range 65–84). UK FIM + FAM scores at
admission were significantly lower in the older than younger
group (115 vs. 134, median difference 15, 95% CI 7–22, P < 0.001).
Average LOS did not differ (median difference 7 days, 95% CI 2 to
15, P = 0.112) (Fig. 1). Both UK FIM + FAM change and efficiency
were significantly higher for older than younger participants
(median difference 7, 95% CI 2–13, P = 0.006, and 0.10, 0.01–0.19,
P = 0.031, respectively).
Overall, 6% (n = 26) and 11% (n = 21) of patients in the younger
and older age groups required LTC on discharge. Older age was
associated with the need for LTC placement (x2 = 4.10, P = 0.043).
A total of 70% patients had acquired brain injury, 11%
progressive neurological disorder, 10% spinal cord injury and 6%
peripheral neuropathy (Table 1).
342 T.C. Khoo et al. / Annals of Physical and Rehabilitation Medicine 63 (2020) 340–343

Table 1
Characteristics of younger and older groups by diagnosis.

Younger Older Median/mean difference P-value

(<65 years) (65 years) [95% CI]

Acquired brain injury (n = 429)

Sample size 281 148 – –
Sex (% Female) 40 54 – –
Age (years) 52 (43–58) 68 (66–71) – –
LOS (days) 60 (32–116) 74 (41.8–102) 7 [ 2 to 17] 0.129
UK FIM + FAM
Sample size 221 124 – –
At admission 123 111 13 [5–23] 0.004
Change 37.0 41.5 5 [ 1 to 12] 0.111
Efficiency 0.44 0.59 0.12 [0.02–0.24] 0.027
Progressive neurological disorder (n = 70)
Sample size 61 9 – –
Sex (% Female) 56 44 – –
Age (years)* 49.1 (8.7) 69.4 (2.7) – –
LOS (days) 49 (18–91) 27 (11–54) 15 [ 9 to 55] 0.216
UK FIM + FAM
Sample size 47 7 – –
At admission* 126 105 21.5 [ 0.4 to 43.3] 0.054
Change* 18.0 5.3 12.7 [3.5–21.9] 0.009
Efficiency 0.29 0.25 0.29 [ 0.20 to 1.22] 0.309
Spinal cord injury (n = 59)
Sample size 38 21 – –
Sex (% Female) 34 33 – –
Age (years) 56 (48–59) 72 (68–75) – –
LOS (days) 61 (39.5–129.5) 74 (41–122) 2 [–28,32] 0.862
UK FIM + FAM
Sample size 29 18 – –
At admission* 148 136 12.0 [ 2.5, 26.5] 0.102
Change 18.0 20.0 5 [–7,17] 0.387
Efficiency 0.31 0.35 0.03 [ 0.21, 0.26] 0.686
Peripheral neuropathy (n = 34)
Sample size 20 14 – –
Sex (% Female) 70 50 – –
Age (years) 56 (45.3–59.3) 72.5 (68.5–74.8) – –
LOS (days) 53 (30.3–90.5) 77 (36.5–150.5) 23 [ 15 to 63] 0.189
UK FIM + FAM
Sample size 15 13 – –
At admission* 132 119 13.0 [ 10.8 to 36.9] 0.272
Change* 36.5 49.2 12.7 [ 6.4 to 31.8] 0.183
Efficiency 0.41 0.45 0.17 [ 0.41 to 0.69] 0.461
Others (n = 24) Data not analysed

Data are median (interquartile range) or * mean (SD). Mann-Whitney U test or Student t test used to compare values between younger and older groups. LOS: length of stay;
UK FIM + FAM: UK Functional Independence Measure + Functional Assessment Measure.

4. Discussion setting, it is difficult to explain why older patients had lower

This study aimed to uncover any differences in outcome after
inpatient neurorehabilitation between younger and older adults
assessed as having rehabilitation potential. The 2 age groups did
not differ in LOS, but both UK FIM + FAM change and efficiency
were significantly higher in the older than younger age group, even
though admission UK FIM + FAM scores were significantly lower in
the older group. The findings suggest that this group of older
patients showed more functional gain over their inpatient stay, and
may reflect a difference in trajectory of natural recovery as an
inpatient in favour of older patients. An alternative explanation is
related to the arbitrary age threshold of 65 years chosen and the
subsequent selection of patients. All patients are assessed
for rehabilitation potential regardless of age before admission to
an inpatient specialist neurorehabilitation unit, but patients
< 65 years old with perceived limited rehabilitation potential
may be admitted due to the societal expectation that they should
be given an ‘‘opportunity’’ for rehabilitation in view of their
relative young age. This situation would create a selection bias
leading to better functional outcomes in older patients when
compared to younger patients. However, without access to data on
pre-morbid functional status or clinical course within the acute
functional status at admission than younger patients.
These results contrast with those of a retrospective matched
cohort study of 267 older patients (55 years) demonstrating that
older patients with traumatic brain injury benefited from acute
rehabilitation, but this benefit was associated with longer
rehabilitation LOS and lower functional outcome as compared
with younger patients [7]. In a more recent retrospective study of
1419 patients with traumatic brain injury, 24% were  65 years
and these older patients showed less functional gain over
admission as compared with younger patients. This was also
associated with lower resource investment in older patients, with
shorter rehabilitation LOS and fewer therapy sessions. However,
whether this finding was due to older patients not being able to
tolerate higher levels of therapy intensity is unclear [10].
While direct comparisons to these studies cannot be made, the
main reason likely explaining the difference in results is that these
studies used arbitrary age thresholds to define patient groups.
Biological age reflects the impact of frailty and pre-existing co-
morbidities on health and functioning and may predict outcome
more than chronological age [16]. Applying an age cutoff without
considering rehabilitation potential may lead to inappropriate
neurorehabilitation admissions, with frail older patients not
 T.C. Khoo et al. / Annals of Physical and Rehabilitation Medicine 63 (2020) 340–343
gaining as much from more intensive rehabilitative approaches.
However, as highlighted from these studies, older patients in
general still benefit from specialist neurorehabilitation.
Results were similar in patients with acquired brain injury,
spinal cord injury and peripheral neuropathy. However, the
pattern was reversed for patients with progressive neurological
disorders, with UK FIM + FAM being significantly lower for older
than younger patients and associated with shorter LOS that did not
reach statistical significance. This finding agrees with the idea that
as patients with progressive neurological disorders age, their
rehabilitation potential decreases with the accumulation of
gradually progressing impairments. The shorter LOS in older
patients is likely attributable to the presence of already established
support within the community before admission. The UK
FIM + FAM may not fully capture the benefit of inpatient specialist
neurorehabilitation for patients with progressive neurological
disorders who are older with more advanced stages of disease
because by definition, their functional outcomes will always be
lower than younger patients who are at an earlier stage of disease.
Goal attainment scaling may be a more sound measure of the
effectiveness of inpatient rehabilitation for this group [17].
The need for LTC placement at discharge was significantly
associated with older age, which suggests that older patients have
higher care needs on discharge despite similar functional gains.
Although increasing age is a predictor of eventual care home
placement [18,19], discharge destination is largely influenced by
wider social factors, such as the availability of community or
family support and funding for LTC placement [18–20], which this
study is not able to account for. Statutory standards for LTC are
more stringent for patients < 65 years old, and thus placements
are less readily available. Also, a likely societal expectation is the
greater acceptability of older patients going to LTC placement on
leaving the healthcare setting as compared with younger patients,
which can also affect discharge planning.
The main limitations of this study are its retrospective design
and the selection bias introduced by triaging older patients with
better rehabilitation potential as previously discussed. This bias
risk is further accentuated by the fact that older patients
represented only 32% of the study sample. However, eliminating
this bias pragmatically is difficult because subjecting older patients
with poor rehabilitation potential to intensive rehabilitation is
both counter-productive for the patient and a suboptimal use of
limited resources.
This study also has potential for referral bias in that only older
patients with better rehabilitation potential were referred to
neurorehabilitation services, whereas those thought to have less
potential were referred directly to geriatric services. This referral
bias was partly ameliorated in unit 2, in which referred patients
were discussed within a collaborative, multi-disciplinary setting
with representation from both neurorehabilitation and geriatric
services to determine the most appropriate patient placement.
The heterogeneity of the sample is another shortcoming. The
natural history of disease can affect recovery trajectory and
rehabilitation potential, which can differ greatly across diagnostic
groups. This study has tried to control for this heterogeneity by
performing sub-group analysis with more homogenous but smaller
samples at the expense of statistical validity. However, apart from
patients with progressive neurological disorders, the study
demonstrated comparable outcomes across a range of diagnoses.
5. Conclusion
Older adults above the ‘‘working-age’’ considered to have
rehabilitation potential show similar if not greater functional gains
343
from inpatient specialist neurorehabilitation as compared with
younger adults. Age alone should not exclude admission to
inpatient specialist neurorehabilitation for older adults.
Funding
This study received no specific grant from any funding agency
in the public, commercial or not-for-profit sectors.
Disclosure of interest
The authors declare that they have no competing interest.
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