Rehabilitation Outcomes in Saudi Arabian Elderly Patients

Introduction and Research Context

In Saudi Arabia, elderly patients constantly face a need for orthopedic surgery — including hip and knee replacement, leg amputation, and similar procedures — all of which require subsequent rehabilitation and physical therapy. This study poses the central question: What are the main factors that facilitate recovery and discharge in the rehabilitation of elderly patients in Saudi Arabia, and what are the barriers? The study examines the international literature on rehabilitation among elderly persons to identify common themes that researchers have highlighted as significant. It then performs a retrospective analysis of medical records of all patients aged 55 years and older who underwent rehabilitation or physical therapy from 2010 to 2016 at either of the two main hospitals in Riyadh, Saudi Arabia. The study offers conclusions based on this analysis and identifies the main factors that emerge from a review of the data.

Research Question and Hypothesis

Research question: What are the main factors affecting rehabilitation outcomes in Saudi Arabian elderly patients?

Hypothesis: The factors that primarily affect rehabilitation outcomes in Saudi Arabian elderly patients are cognitive function, nutrition, pre-injury functionality, gender, type of surgery or operation, and depression.

Methodology

This is a retrospective study that uses medical records of all participating patients who are 55 years and older and who underwent rehabilitation or physical therapy between 2010 and 2016. The data are procured from the two main hospitals in Riyadh, Saudi Arabia.

Literature Review

The literature regarding recovery facilitation and barriers to discharge for elderly persons undergoing rehabilitation has focused on a number of areas in recent years — among them prevention, outcomes, and the relationships among variables. This survey examines a range of these studies in order to provide an overview of rehabilitation challenges in both developed countries like the United States, where the population is aging and a high prevalence of falls exists, and in the Middle East — specifically Saudi Arabia — where osteoporosis is prevalent, secondary to low vitamin D levels, along with high rates of car accident-related injuries.

Chin, Ng, and Cheung (2008) identify predictors of rehabilitation outcomes in their study and development of a case-mix system for hip fracture patient rehabilitation. They utilize a prospective cohort study to examine a sample of patients with an average age of 82 years, assessing a variety of outcomes — from mortality to hospital length of stay, placement, ambulation, and activity at time of discharge and six months post-discharge. Data were assessed using multivariate analysis, and predictors were validated based on this assessment. The researchers found that the two best predictors of outcomes were the Abbreviated Mental Test score (a score lower than 6) and the Functional Independence Measures score (a score lower than 75). These predictors, if identified at the time of patient admission, were reliably associated with predictable outcomes. The researchers concluded that the most readily identifiable factors impacting rehabilitation of the elderly were cognition and the level of daily activity to which the elderly patient had been accustomed. This study supports the hypothesis of the current study by providing evidence of two key factors — cognitive function and pre-injury functionality.

According to Hershkovitz, Kalandariov, Hermush, Weiss, and Brill (2007), all of the same factors identified in the hypothesis — except gender — were found to be variables impacting rehabilitation of elderly persons suffering from hip injuries. Effective rehabilitation depended most upon depression levels and nutritional status, which were also the most correctable of the variables. The most effective strategy for securing a successful rehabilitation was found to be time-based: early intervention produced the best results. The longer rehabilitation was delayed, the less likely the intervention was to succeed. This study is particularly valuable because it highlights and identifies each of the variables to be tested in the current study and provides logical support for the hypothesis.

Oh, Perlas, Lau, Gandhi, and Chan (2016) focus on the functional outcome and cost-effectiveness of outpatient versus inpatient care for foot and ankle surgery patients and find that the variables impacting discharge were related to both outpatient and inpatient services. The overall finding was that ambulatory perineural infusion of local anesthetic could be regarded as a cost-effective alternative to inpatient care and its associated costs post-surgery. This study is relevant because it underscores the value of care implemented prior to major surgery or hospitalization. Elderly persons can benefit from preventive care that may theoretically improve discharge rates and more effectively support a positive and timely hospital stay should one become necessary.

The study by Luk, Chiu, and Chu (2011) examines the role of gender as a variable in rehabilitation outcomes among elderly Chinese patients, making it a useful reference for this study, which includes gender in its hypothesis as a factor affecting rehabilitation. Their study finds that gender is meaningful in the rehabilitation process and that women "achieved a better functional outcome but a poorer motor outcome on discharge," thus making female gender a positive indicator of functional outcome and a negative indicator of motor outcome (p. 28). The study isolated gender as a variable by using a controlled comparison of data drawn from 1,795 patients in two convalescence hospitals in Hong Kong. The study also identified age, urinary incontinence, living arrangement, admission Emergency Medical Services status, chest infection, cognition, and admission Barthel Index score as predictors. The study concluded that while gender was not the only or primary factor in predicting rehabilitation outcomes, it was a meaningful one and should be considered in rehabilitation studies and in the development of intervention methods. The identification of multiple interacting factors in this study also supports the notion that a wide range of variables operates within the rehabilitation process and that identifying the primary ones while accounting for secondary variables is important.

McGilton, Mahomed, Davis, Flannery, and Calabrese (2009) examined 31 elderly patients admitted to hospital following a hip fracture. Of the sample, 18 had cognitive impairment following surgery, as indicated by a Mini-Mental State Examination score at or below 23. Lengths of stay did not differ among patients, nor did rehabilitation efficiency. The study concluded that rehabilitation staff can more effectively provide quality care for patients with cognitive impairment by understanding how frequently this condition occurs post-operation, and that quality care can be planned in advance when it is known that cognitive impairment does not necessarily reduce rehabilitation efficiency. In other words, the study shows that cognitive functionality is not a reliable predictor of rehabilitation success for elderly persons. This finding contradicts those of Chin et al. (2008), Hershkovitz et al. (2007), and others described above — indicating that there is no unanimous consensus among researchers regarding the degree to which various factors and variables influence rehabilitation outcomes in elderly patients. For this particular study, culture, gender, age, and other factors may have played more significant roles in outcomes. Although the study does not address these other variables in depth, it is helpful overall in that it presents an alternative perspective on the concept of rehabilitation.