Faculty Bibliography

Background: Among older adults with cardiovascular disease (CVD), cardiac rehabilitation (CR) has multiple benefits including improved quality of life and reduced mortality. Despite the known benefits of CR, early termination (ET) by patients (attending <12/36 recommended sessions) may attenuate these benefits. Our aim was to determine the incidence of ET in our older adult patient population, as well as risk factors associated with this outcome.
Method(s): We reviewed records from 792 consecutive older adult patients (>= 65 years old) enrolled in the NYU Langone Rusk CR program (2013-2017). Sessions attended, demographics, comor-bidities, and primary referral diagnosis were abstracted. We analyzed the overall rate of ET (defined as attending <12 sessions). Categorical variables were described with percentages and continuous variables with mean values. Multivariable logistic regression was subsequently used to analyze predictors of ET, considering age, race, ethnicity, sex, body mass index, diabetes, chronic lung disease, coronary artery disease, heart failure, and stroke.
Result(s): In our total study population, mean age was 74 +/- 7 years, mean BMI was 26 +/- 5, 38% were female, and 18% were nonwhite. Most patients (65%) were referred to CR due to ischemic heart disease (chronic stable angina, post-myocardial infarction, CABG, or elective PCI), with an additional 23% referred for valvular heart disease, 9% for systolic heart failure, and 3% for congenital heart disease. Early termination occurred in 129 patients (16.3%). Patients who terminated early were significantly older (75.6 vs. 73.9, p=0.005) and less likely to have coronary artery disease (13.6% vs. 19.5%, p=0.03). After multivariable logistic regression, the independent risk factors for ET were age (adjusted OR 1.04, 95% CI 1.01-1.07) and Hispanic ethnicity (adjusted OR 2.32, 95% CI 1.01-5.33).
Conclusion(s): Nearly 1 in 6 older adults terminated CR within 1 month (<12/36 sessions), potentially limiting the benefits of CR within this subgroup. Among factors we analyzed, age and Hispanic ethnicity were risk factors for ET, but the overall strength of associ-ation was weak. Further research is necessary to identify novel risk factors for ET in order to better target prevention efforts

BACKGROUND: Most early mobility studies focus on patients on mechanical ventilation and the role of physical and occupational therapy. This Performance Improvement Project (PIP) project examined early mobility and increased intensity of therapy services on ICU patients with and without mechanical ventilation. In addition, Speech-Language Pathology rehabilitation was added to the early mobilization program. OBJECTIVE: 1. To assess the efficacy of early mobilization of patients with and without mechanical ventilation in the intensive care units (ICUs) on length of stay (LOS) and patient outcomes. 2. To determine the financial viability of the program. DESIGN: PIP. Prospective data collection in 2014 (PIP) compared to a historical patient population in 2012 (pre-PIP). SETTING: Medical and surgical ICUs of a Level 2 trauma hospital. PATIENTS: 160 in the PIP and 123 in the pre-PIP. INTERVENTIONS: Interprofessional training to improve collaboration and increase intensity of rehabilitation therapy services in the MICU and SICU for medically appropriate patients. MEASUREMENTS: Demographics; intensity of service; ICU and hospital LOS; medications; pain; discharge disposition; functional mobility; average cost per day. MAIN RESULTS: Rehabilitation therapy services increased from 2012 to 2014 by approximately 60 minutes per patient. The average ICU LOS decreased by more than 20% from 4.6 days (pre-PIP) to 3.8 days (PIP) (p=.05). A decrease of 30% was observed in the floor bed average LOS from 6.0 days (pre-PIP) to 3.4 days (PIP) (p<.01). An increased percentage of PIP patients, 40.5%, were discharged home without services compared to 18.2% in the pre-PIP phase (p<.01). Average cost per day in the ICU and floor bed decreased in the PIP group resulting in an annualized net cost savings of $1.5 million. CONCLUSIONS: The results of the PIP indicate that enhanced rehabilitation services in the ICU is clinically feasible, results in improved patient outcomes, and is fiscally sound. Most early mobility studies focus on patients on mechanical ventilation. The results of this PIP project demonstrate that there are significant benefits to early mobility and increased intensity of therapy services on ICU patients with and without mechanical ventilation. Benefits include reduced hospitalization LOS, decreased health care costs and decreased need for post-acute care services.

OBJECTIVE: This article reviews the prevalence, underlying mechanisms, and challenges of treating encephalopathy and delirium in the postsurgical and medically compromised cardiopulmonary patient receiving services on an acute inpatient rehabilitation unit. Additionally, pertinent information is provided on conducting an evaluation to assess for neurocognitive sequelae of the above-mentioned conditions to help achieve better treatment outcomes. METHOD: Review of the medical and neuropsychology literature is provided along with 2 case reports to illustrate evaluation of a persisting toxic-metabolic encephalopathy and a resolving delirium and the treatment team's effectiveness in producing a more optimal treatment outcome. The unique role of the rehabilitation psychologist, special treatment considerations, and the importance of integrated follow-up neurorehabilitation services for the cardiopulmonary patient and caregivers also are emphasized. RESULTS: Encephalopathy and delirium are 2 related, but somewhat different, conditions that can emerge postoperatively, any time during acute care hospitalization, and often enough, during impatient or subacute-care rehabilitation. Their association with long-term harm and poor outcome warrant early identification and immediate medical intervention. IMPLICATIONS: Encephalopathy and delirium can significantly affect rehabilitation outcomes and, as such, rehabilitation psychologists are encouraged to systematically screen for the presence of delirium and encephalopathy in the cardiopulmonary rehabilitation setting so to enhance treatment efficacy and quality of life in affected individuals. (PsycINFO Database Record

BACKGROUND: The Dyspnea Management Questionnaire (DMQ) is a measure of the psychosocial and behavioral responses to dyspnea for adults with COPD. The research objectives were to evaluate the reliability and validity of an expanded DMQ item pool, as a preliminary step for developing a computer adaptive test. METHODS: The original 66 items of the DMQ were used for the analyses. The sample included 63 women and 44 men with COPD (n = 107) recruited from two urban medical centers. We used confirmatory factor analysis to test the factor structure of the DMQ and its underlying cognitive-behavioral theoretical base. The internal consistency and test-retest reliability, and breadth of coverage of the expanded DMQ item bank were also evaluated. RESULTS: Five distinct dyspnea domains were confirmed using 56 original items of the DMQ: dyspnea intensity, dyspnea anxiety, activity avoidance, activity self-efficacy, and strategy satisfaction. Overall, the breadth of items was excellent with a good match between sample scores and item difficulty. The DMQ-56 showed good internal consistency reliability (alpha = 0.85-to 0.96) and good preliminary test-retest reliability over a 3-week interval (ICC = 0.69-0.92). CONCLUSIONS: The DMQ demonstrated acceptable levels of reliability and validity for measuring multidimensional dyspnea outcomes after medical, psychological, and behavioral interventions for adults with COPD

PURPOSE: To develop and psychometrically test the Dyspnea Management Questionnaire (DMQ), a new multidimensional measure of dyspnea in adults with chronic obstructive lung disease. PARTICIPANTS: Eighty-five participants were recruited with diagnoses of chronic obstructive pulmonary disease (COPD, n = 73) and asthma (n = 12). The total sample was predominately female (65%) and married (34%), with 64.9% white and a mean age of 75 years (SD = 9.6, n = 76), diagnosed with pulmonary disease 4.8 years ago (SD = 4.4), 32% requiring the use of supplemental oxygen. Participants were also African American (29.9%), Asian (2.6%), and Hispanic (2.6%); n = 77. METHODS: An initial item pool of 74 items was drawn for the DMQ aided by qualitative interview data, literature review, and pilot testing with 3 adults with COPD. Several analyses were used to reduce the item pool. An interdisciplinary panel of 12 experts evaluated the content validity of the DMQ items. To evaluate test-retest reliability, respondents with stable COPD (n = 26) completed the questionnaire twice within a mean interval of 18 days (SD = 7.17). The DMQ was compared with the Medical Outcomes Study 12-Item Short-Form (SF-12) Health Survey, the Seattle Obstructive Lung Disease Questionnaire, and the Hospital Anxiety and Depression Scale. RESULTS: The resulting DMQ is a 30-item scale that measures 5 conceptually derived dimensions: dyspnea intensity, dyspnea-related anxiety, fearful activity avoidance, self-efficacy for activity, and satisfaction with strategy use. It has a 7-point Likert-type scale and third Flesch-Kincaid reading grade level. A panel of 12 experts supported the content validity of the DMQ. It showed high internal consistency (alpha = .87 to .96) and test-retest reliability over 2.5 weeks (intraclass correlation coefficient = 0.71 to 0.95). Dyspnea intensity, dyspnea-related anxiety, and fearful activity avoidance subscales of DMQ-30 and composite score were moderately to highly correlated with 3 Seattle Obstructive Lung Disease Questionnaire dimensions (r = 0.44-0.83), Medical Outcomes Study 12-Item Short-Form scales (r = 0.41-0.57), and Hospital Anxiety and Depression Scale-Anxiety (r = -0.59 to -0.65). Two of DMQ's subscales, self-efficacy for activity and satisfaction with strategy use, correlated mildly with Seattle Obstructive Lung Disease Questionnaire (r = 0.28 and 0.27, respectively). Some very low correlations for DMQ-30's satisfaction with strategy use compared with the Medical Outcomes Study 12-Item Short-Form provided preliminary support for its divergent construct validity. The DMQ-30 discriminated adults with COPD requiring supplemental oxygen from those not requiring it. CONCLUSIONS: The DMQ addresses the need for a more comprehensive, multidimensional assessment of dyspnea, especially for anxious patients with COPD, in order to better guide the appropriate application of dyspnea management interventions and measure pulmonary rehabilitation outcomes. The DMQ can help add insights into the benefit of adjunctive therapies such as psychoeducation, controlled breathing strategies, and cognitive-behavioral approaches in pulmonary rehabilitation for anxious patients with COPD.

Chronic obstructive pulmonary disease (COPD) is the most common form of primary pulmonary disability. Few effective treatment options exist for it, but recently, lung-volume reduction surgery (LVRS) has been shown to be effective in selected patients with emphysema. Pulmonary rehabilitation is an integral part of the preparation for and recovery from the procedure and has significant benefit in helping to improve the quality of life and conditioning of patients with COPD who undergo LVRS. Overall Article Objectives: (a) To describe the role of pulmonary rehabilitation in LVRS, (b) to understand the components of a comprehensive pulmonary rehabilitation program, and (c) to describe the effects of a pulmonary rehabilitation program