Abstract
The prevalence and extent of cognitive-communication disorders and factors that have impact on outcomes are examined in the burn population within an inpatient rehabilitation facility. A retrospective data analysis was conducted on adults diagnosed with burn injury (n = 144). Descriptive statistics were used to identify the prevalence of cognitive-communication deficits on admission and discharge. The main outcomes were cognitive-communication ratings on discharge from inpatient rehabilitation as measured by the memory and problem-solving domains of the Functional Independence Measure (FIM®) and composite score of the Functional Communication Measure (FCM). Medical, demographic and rehabilitation predictors of the main outcomes were assessed using regression analyses. On admission to inpatient rehabilitation, 79% of the total population presented with cognitive-communication impairments, and of them, 27% presented with persistent deficits on discharge. Admission FIM memory score, marital status, and age were significant predictors of discharge FIM memory score. Admission FIM problem-solving score, age, marital status, and prehospital living-with were significant predictors of discharge FIM problem-solving score. Admission FCM score and age were significant predictors of discharge FCM cognitive score. Persons with burn injuries are at risk for cognitive-communication impairments, which may persist after inpatient rehabilitation. FIM data obtained on admission can be used as a screening tool to identify these at-risk patients. Future work is needed to assess the efficacy of speech-language pathologist intervention for cognitive-communication deficits within the burn injury population.
Medical advances in burn care have improved substantially during the past 40 years, reducing mortality within this population.1 Nonetheless, burn survivors often experience significant functional impairments that persist beyond the acute care stage of recovery.2 These patients therefore frequently transition to a postacute setting for inpatient rehabilitation where functionality and quality of life become the primary focus of treatment. Multiple intensive sessions with different therapies on a daily basis are required to achieve optimal results. The presence of cognitive deficits, in particular, can potentially impair understanding and retention of instructions and adaptive techniques provided by the multidisciplinary team and rehabilitation specialists. These deficits, if not directly addressed, can slow or alter the recovery process.
Recent research findings highlight the presence of cognitive-communication impairments in the burn injury population.3 Cognition is a set of complex mental processes that includes attention, perception, memory, organization, and executive function skills. Areas of function affected by cognitive impairments include behavioral self-regulation, social interaction, activities of daily living, learning and academic performance, and vocational performance.4–6 Within the clinical context, cognition is often simplified into three main domains of attention, memory, and problem-solving skills. Given that these cognitive domains directly contribute to a person’s overall functional communication skills, speech-language pathologists (SLPs) use the term cognitive-communication to encompass and describe these skills. The role of the SLP is to identify, diagnose, and treat persons with cognitive-communication disorders, which is consistent with the framework of the World Health Organization International Classification of Functioning Disability and Health.4–7
In the burn population, notable cognitive-communication impairments emerge as the patients become more alert and active and as they are faced with increased demands to resume activities of daily living, manage personal affairs, and return to work, family, and/or academic obligations. This observation has been explored further in a recent study by Purohit et al,3 in which the cognitive status of patients with burn injury were compared to those from other rehabilitation programs and with different diagnoses including spinal cord injury, amputation, polytrauma with multiple fractures, and hip replacement in a national sample. Their findings indicated that patients with burn injuries had significantly lower total cognitive Functional Independence Measure (FIM®) scores on admission as compared to those same cognitive ratings within the other rehabilitation populations included in this study.3 Additionally, when considering the different components of the total cognitive FIM score, a significantly lower memory score in the burn injury group appeared to account for this difference.3
Long-term cognitive impairments have been documented for patients with critical illnesses and intensive care unit treatment.8 In the burn population, anoxia, toxic fume inhalation, medical complications from the primary injury (eg, dehydration, electrolyte abnormalities, etc.), hypoperfusion secondary to volume depletion and shock, and use of centrally acting medications and anesthesia are all potential reasons for cognitive impairment.3 Persistent cognitive impairments have implications for health, quality of life, and rehabilitation outcomes in many patient populations.9 Therefore, identifying and understanding the potential cognitive-communication deficits in patients with burn injuries may play a critical role in better projecting the functional outcomes and prognosis, as well as assist in providing appropriate services for this population.
The purpose of this article is to examine the prevalence and extent of cognitive-communication deficits during the course of inpatient rehabilitation and to determine the impact of medical, demographic, and rehabilitation factors on outcomes using standard rehabilitation rating scales—the Functional Independence Measure (FIM) and the Functional Communication Measure (FCM). Secondarily, we examine outcomes for those persons receiving SLP intervention.
METHODS
Setting and Study Population
This study is a retrospective analysis of inpatient rehabilitation facility (IRF) data for patients admitted to the Burn Injury Program at a large regional inpatient rehabilitation hospital from October 2007 to September 2013. Data for this analysis were obtained through the hospital network databases, including electronic medical records, available paper records, Uniform Data Set, and the Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI). Inclusion criteria are (1) age of 18 years or older, (2) a diagnosis of burn injury as indicated by corresponding impairment codes and admission to the multidisciplinary Burn Injury Program, and (3) a complete data set with variables of interest available in the hospital database. Some patients required multiple discharges and readmissions for various reasons (eg, planned surgery, change of status, medical complications, etc.). These cases were considered one course of treatment from initial admission to final discharge within the inpatient rehabilitation setting. In addition to a primary diagnosis of a burn injury, some patients within this cohort also had concurrent injuries including limb amputation and multiple additional traumatic injuries. Although the patients coded as multitrauma at the IRF level also had primary diagnosis of burn injury, it was difficult to ascertain the number of patients with comorbid possible mild brain injury as not all cases of suspected traumatic and/or anoxic brain injury were well documented. This information was obtained either from discharge records from the acute care facility, the IRF History and Physical, or Uniform Data Set. All patients fulfilled criteria for inpatient rehabilitation, which includes the ability to participate in 3 hours daily of therapy at least 5 days per week and the need for daily medical attention from a physician. The IRF burn population has been previously described in a large national sample.10 This study was conducted at an inpatient rehabilitation hospital, and the authors do not have access to analogous data for patients not admitted to the rehabilitation facility.
All referrals for SLP evaluation were at the discretion of the referring provider (physician) on admission, or at the recommendation of other disciplines (ie, occupational therapy, physical therapy, nursing) if deficits were suspected typically within the first week of rehabilitation. Following referral from a physician, SLP assessment was conducted using standardized, norm-referenced tools as well as via nonstandard/informal procedures and collection of case history information regarding premorbid abilities, educational level, and work situation. When deficits were identified and evaluation results were below normative and/or baseline levels, a specific SLP diagnosis (eg, cognitive-linguistic disorder, aphasia, dysarthria, etc.) was made. This diagnosis is based on the overall presentation of the patient’s cognitive-communication profile, and is part of the SLP’s scope of practice. Those patients were then enrolled in a skilled SLP treatment program for an additional 30 to 60 minutes per day for 3 to 5 days per week.
Study Variables and Outcome Measures
Demographic data collected included age, sex, marital status, prehospital living situation, and preinjury occupational status. Medical and rehabilitation data included TBSA burned (percent decile), presence of head and neck burns, history of ventilation, history of tracheostomy, number of operations, posthospital living situation, and comorbidity tier (low, moderate, and high cost) as identified by the Centers for Medicare and Medicaid Services (CMS) in the IRF-PAI.11 Operations in which general anesthesia was used were counted from date of onset to discharge from IRF. CMS defines a comorbidity as “a secondary condition a patient has in addition to the primary diagnosis for which the patient was admitted to the IRF … and should have significant impact on the patients’ course of treatment ….”11 The CMS comorbidity tiers include both premorbid and concurrent conditions. The variables included in our study analysis were selected based on their relevance and significance to outcomes of burn injury survivors in other studies.2,10,12 See Table 1 for descriptive data on the study population.
Table 1.
Demographic and medical characteristics of study population
| Demographic Variables | Values |
|---|---|
|
| |
| Age, range (mean year) | 18–94 (48.44) |
| Sex male (%) | 70 |
| Married (%) | 34 |
| Prehospital living with another (%) | 75.5 |
| Employed before injury (%) | 51 |
| Prehospital living at home (%) | 95 |
| Medical/Rehabilitation Variables | Values |
| TBSA greater than 30%, (%) | 47 |
| Presence of head/neck burns (%) | 50 |
| Hx of ventilation (%) | 39 |
| Hx of tracheostomy (%) | 35 |
| Posthospital living at home (%) | 96 |
| Comorbidity Tier ICD-9 coding (%) | |
| No cost (A) | 50 |
| High cost (B) | 20 |
| Moderate cost (C) | 19 |
| High cost (D) | 11 |
| Operations with general anesthesia from date of onset to discharge from IRF, mean | 5.81* |
ICD-9, International Classification of Diseases, Ninth Revision; IRF, inpatient rehabilitation facility.
Mean.
Two outcome measures were analyzed in this study: the FIM and the FCM. These were chosen as they both are nationally used, standardized seven-point severity rating tools. Each user must complete a short course and competency test prior to administering these rating scales to patients. They are both frequently used in rehabilitation settings and include the targeted study parameters related to cognitive-communication functioning (Table 2).
Table 2.
Comparison of FIM and FCM
| Level | FIM Problem Solving and Memory | FCM Attention, Memory, Problem Solving |
|---|---|---|
|
| ||
| 7 | Complete I. No helper | I at a complex level without limitations. Effective use of compensations and strategies and self-monitors/corrects |
| 6 | Modified I. Assist needed but no physical contact | Rare-min cues and extra time for complex situations but limits in vocational, social, and avocational activities; usually employs strategies and self-monitors/corrects |
| 5 | Modified D. Patient needs helper to provide supervision or set-up | Min cues and structure for novel situations; rare cues for functional simple routines; mod cues and more time for complex tasks. Difficult to divide attention. Distant S for completion of complex acts and to self-monitor/correct |
| 4 | Min contact A. Patient completes 75% or more | Mod–min cues consistently needed, especially as complexity increases to use external aids. Simple structured, mod complex. Rare distant S for simple tasks. Max cues for complex with Close S. Rarely self-monitors/corrects |
| 3 | Mod A. Completes 50–74% | Mod–max cues for simple routines and to use external aids. Accuracy varies; best on short simple tasks. Close S for all activities |
| 2 | Max A. Helper needed for all tasks. Completes 25–49% | Max cues with participation brief periods of time; may complete for personal or rote tasks but not beyond. Inaccuracies. 1:1 S for all activities |
| 1 | Dependent. Completes less than 25% of task OR requires assist of two helpers | Nonfunctional and dependent |
FIM, Functional Independence Measure; FCM, Functional Communication Measure; A, assistance; S, supervision; I, independent; D, dependent; Min, minimal; Mod, moderate; Max, maximum.
Problem-solving levels: rote, simple, complex. Attention levels: focused, sustained, selective, alternating, divided. Memory levels: personal, routine, functional, novel, complex/lengthy information.
Functional Independence Measure
The FIM is used at 70% of the IRFs in the United States to measure functional status, burden of patient care, and outcomes of medical rehabilitation on admission and discharge.13 The FIM is a standardized instrument that assesses function across a total of 18 domains including 5 cognitive skill areas (comprehension, expression, memory, problem solving, and social interaction) and 13 motor skills areas (eating, bathing, bladder and bowel management, grooming, upper and lower body dressing, locomotion, stairs, toileting, and transfers: bed-chair, toilet, and shower). Each domain is rated with a seven-point ordinal scale from completely dependent (1) to independent (7), with total scores ranging from 18 to 126. The lowest score received in each of the 18 domains during the first three rehabilitation days by any rater is considered the admission score as this is judged to best reflect burden of care across days, time, and activities. The FIM instrument is the current universal standard for measuring outcomes at the IRF level of care, and it has been widely used in the literature as an outcome measure for functional progress.14 The consistent use of the FIM scores allows for comparison of patient populations and outcomes among IRF settings. Although not specific to burn injury, the FIM possesses evidence of validity and reliability as an outcome measure for patients with burn injuries in the inpatient rehabilitation setting.15 The FIM instrument is the only objective measure available for a retrospective analysis of rehabilitation outcomes in this study population. For purposes of this study, we analyzed only the memory and problem-solving FIM scores as burn injuries do not typically result in more focal language disturbances such as aphasia where one would expect to see a decrease in auditory comprehension or verbal expression skills.
Functional Communication Measure
The FCM is an objective outcome measure system that directly relates to and closely examines a person’s cognitive-communication skills, as judged and scored only by an SLP trained in its administration. The FCMs, established by the American Speech-Language-Hearing Association (ASHA), are a series of 15 disorder-specific domains including alaryngeal communication, attention, augmentative-assistive technology, fluency, memory, motor speech, pragmatics, problem solving, reading, spoken language comprehension, spoken language expression, swallowing, voice, voice following tracheostomy, and writing. Each area is rated using a seven-point ordinal scale from least functional (level 1) to most functional (level 7). Scores in areas of impairment are assigned following evaluation and again on discharge, and FCMs are only rated if identified as an area of deficit. These measures have been developed to describe a person’s functional communication and swallowing abilities during the course of SLP intervention and are part of ASHA’s National Outcome Measurement System (NOMS) data collection and reporting tool.16 For purposes of this study, only the FCM domains of attention, memory, and problem solving were analyzed as these represent the most frequent and relevant areas of cognitive-communication deficits in the burn population.
Data Analysis
The FIM is completed by various rehabilitation team members including nursing and therapy disciplines on admission and discharge for all patients admitted to the IRF. In addition, patients referred for a cognitive-communication assessment within the first 3 days of admission also received FIM rating scores by SLPs. Admission and discharge FIM scores in the areas of memory and problem solving were gathered for all burn injury patients who met study inclusion criteria. These scores were analyzed descriptively and via statistical analysis. Discharge FIM scores were represented as a continuous variable, and linear regression analyses were used to determine significant predictors for functional outcomes for both memory and problem-solving domains. Admission FIM score, TBSA category (percent decile), number of operations, comorbidity tier (low, moderate, and high cost), age (decile), prehospital employment status (working vs not working), marital status (married vs single), and prehospital living situation (living alone vs living with another) were the independent variables considered.
A subset of patients admitted to the Burn Injury Program referred for SLP evaluation were examined. Of those referred, 86% were subsequently diagnosed with cognitive-communication deficits and received speech therapy treatment. For this patient subset, FCM scores were also assigned at time of assessment (Figure 1). Per ASHA protocol, FCM domains are rated only by SLPs after referral and evaluation are completed and only for those particular cognitive-communication skills determined to be a deficit area and part of the patients’ treatment plan. There were instances where attention, memory, and problem-solving FCM scores could not be obtained from medical record for both admission and discharge because of inability to access older records electronically or omission in data reporting. To account for instances like this, an FCM cognitive composite score encompassing either attention, memory, or problem-solving scores that were recorded on both admission and discharge was calculated and used for the analysis. The admission and discharge FCM cognitive scores collected for each patient consisted of the lowest FCM score on admission across the three domains of attention, memory, and problem solving that also had a corresponding discharge score. Clinically, the cognitive domains of attention, memory, and problem solving are intertwined; therefore, a deficit in any one of these areas likely has impact on functional performance within these other domains. These scores were also analyzed both descriptively and via statistical analysis.
Figure 1.
Patient flow diagram.
From a clinical perspective, there is a significant difference in burden of care for patients with FCM ratings of 1 to 4 vs patients with FCM rating from 5 to 7. Patients rated within the 1 to 4 range require constant assistance or supervision, whereas those with rating scores in the 5 to 7 range are at a modified to fully independent level and may only require intermittent supervision or assistance. While improving from a rating of 3 to 4 denotes progress, advancing from a rating of 4 to 5 represents a more clinically meaningful change. Because our sample of patients with FCM data was small, we collapsed the outcome measure discharge FCM into dichotomous variables of dependent (scores 1–4) and modified independent (scores 5–7). A logistic regression was then used to assess significant covariates for functional cognitive-communication outcomes as captured by the FCM scale. Independent variables included in this analysis were admission FCM score, TBSA category (percent decile), number of operations, comorbidity tier (low, moderate, and high cost), age (decile), and prehospital employment status (working vs not working).
As part of our secondary aim, a preliminary examination of subjects’ cognitive-communication performance while on SLP program was conducted in order to identify patterns of progress within the inpatient rehabilitation setting. Given the retrospective nature of this study, subjects were not randomized and treatment factors were not controlled. A series of t-tests (assuming unequal variance between groups) were used to examine changes in FCM cognitive composite score and cognitive-communication FIM scores (memory and problem solving) on admission and discharge.
RESULTS
Description Inclusion/Exclusion and Subjects on SLP Program
FIM scores were obtained for a total of 144 patients, and all these patients were included in the analysis of FIM memory. For FIM problem solving, five patients were excluded from the final model analysis because of missing data for prehospital living status. For number of operations, three patients were excluded because data were not available or they did not have surgery requiring general anesthesia. Eighty-four subjects of the 144 total burn patients (58%) were referred to SLPs for a cognitive-communication evaluation, and of them, 86% were diagnosed by SLPs as demonstrating cognitive-communication deficits. Ultimately, 72 patients of the 144 total burn patients (50%) were diagnosed and received skilled treatment by an SLP (Figure 1).
In the FCM analysis, 68 individuals were included, as three people were missing employment status and one person was missing TBSA category score. Within this burn population, attention, memory, and/or problem-solving deficits were the most prominent deficit areas and impairments in at least one of these areas was present in all patients receiving SLP services.
Summary of Scores of Cognitive-Communication Outcomes
Patients with low admission FIM scores (ie, scores of 4 or below) who improved to higher discharge scores (5 or above) represented important changes in function in that they advanced from a dependent level, requiring 24-hour supervision, to a more independent level (intermittent supervision to fully independent). For those with low admission FIM problem-solving and memory scores, functional gains were noted in 77% and 70%, respectively, on discharge. Meanwhile, 13% of those with low admission problem-solving and memory scores presented with significant, persistent cognitive deficits at the time of discharge, requiring the need for constant supervision.
In addition, it is important to note that individuals rated with an FIM score of 5 (modified independent level) means that they demonstrate adequate memory and problem-solving skills to perform basic self-care tasks in order to live alone; however, they require intermittent support for the higher level executive function skills and likely more than the usual amount of time needed for tasks such as academic, vocational, and community reentry. When we added these patients rated with FIM score of 5 (milder cognitive deficits) to the cohort of patients rated with FIM score of 4 or below, 79% of the burn injury population examined within this study presented with cognitive-communication deficits on admission to inpatient rehabilitation. A total of 27% presented with persistent deficits on discharge from the IRF setting, requiring some level of supervision or support ranging from intermittent to constant (Tables 3 and 4).
Table 3.
Frequency of admission and discharge FIM problem-solving scores (n = 144)
| FIM Problem-Solving Score—Admission | FIM Problem-Solving Score—Discharge |
|||||||
|---|---|---|---|---|---|---|---|---|
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | Total | |
|
| ||||||||
| 1 | 4 | 1 | 0 | 1 | 1 | 1 | 2 | 10 |
| 2 | 0 | 1 | 1 | 1 | 1 | 1 | 0 | 5 |
| 3 | 0 | 0 | 4 | 2 | 5 | 2 | 6 | 19 |
| 4 | 0 | 0 | 1 | 0 | 6 | 12 | 17 | 36 |
| 5 | 0 | 0 | 0 | 3 | 7 | 11 | 23 | 44 |
| 6 | 0 | 0 | 0 | 0 | 0 | 7 | 14 | 21 |
| 7 | 0 | 0 | 0 | 0 | 0 | 0 | 9 | 9 |
| Total | 4 | 2 | 6 | 7 | 20 | 34 | 71 | 144 |
FIM, Functional Independence Measure; FCM, Functional Communication Measure.
Shaded area = patients with persistent cognitive deficits on discharge (FIM or FCM scores of 5 or below).
Table 4.
Frequency of admission and discharge FIM memory scores (n = 144)
| FIM Memory Score—Admission | FIM Memory Score—Discharge |
|||||||
|---|---|---|---|---|---|---|---|---|
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | Total | |
|
| ||||||||
| 1 | 2 | 2 | 1 | 1 | 0 | 1 | 0 | 7 |
| 2 | 0 | 0 | 1 | 1 | 0 | 1 | 1 | 4 |
| 3 | 0 | 0 | 3 | 2 | 4 | 1 | 8 | 18 |
| 4 | 0 | 0 | 1 | 3 | 5 | 4 | 16 | 29 |
| 5 | 0 | 0 | 0 | 0 | 10 | 9 | 22 | 41 |
| 6 | 0 | 0 | 0 | 1 | 1 | 8 | 17 | 27 |
| 7 | 0 | 0 | 0 | 0 | 1 | 1 | 16 | 18 |
| Total | 2 | 2 | 6 | 8 | 21 | 25 | 80 | 144 |
FIM, Functional Independence Measure; FCM, Functional Communication Measure.
Shaded area = patients with persistent cognitive deficits on discharge (FIM or FCM scores of 5 or below).
In examining the FCM cognitive composite data for the 72 patients who received SLP intervention, 40% of the patients improved from a dependent level, meaning low admission FCM scores of 4 or below and requiring 24-hour supervision, to a more independent level (intermittent supervision to fully independent level). However, 10% of those with low admission FCM scores continued to demonstrate low FCM scores at the time of discharge. In the case of FCM scores, although ratings of 5 reflect functional gains toward independence, some degree of support and often extra time are still required to complete higher level tasks. When we include patients rated with FCM scores of 5 to the cohort of those rated with FCM score of 4 or below, a total of 35% require minimal to occasional support with complex tasks and these breakdowns may interfere with the individual’s functioning in vocational, avocational, and social activities (Table 5).
Table 5.
Frequency of admission and discharge FCM scores for patients on SLP program (n = 72)
| FCM Cognitive Composite Score—Admission | FCM Cognitive Composite Score—Discharge |
|||||||
|---|---|---|---|---|---|---|---|---|
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | Total | |
|
| ||||||||
| 1 | 0 | 1 | 0 | 0 | 2 | 1 | 0 | 4 |
| 2 | 0 | 0 | 1 | 0 | 2 | 1 | 0 | 4 |
| 3 | 0 | 0 | 0 | 0 | 4 | 1 | 0 | 5 |
| 4 | 0 | 0 | 1 | 4 | 7 | 8 | 3 | 23 |
| 5 | 0 | 0 | 0 | 0 | 3 | 14 | 16 | 33 |
| 6 | 0 | 0 | 0 | 0 | 0 | 1 | 2 | 3 |
| 7 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| Total | 0 | 1 | 2 | 4 | 18 | 26 | 21 | 72 |
FIM, Functional Independence Measure; FCM, Functional Communication Measure.
Shaded area = patients with persistent cognitive deficits on discharge (FIM or FCM scores of 5 or below).
Summary of Regression Analysis Results
Admission FIM memory score, marital status, and age were all significant independent variables of discharge FIM memory score (P < .01). TBSA decile, comorbidity tier, number of operations, and employment status were not significant (Table 6). Those who were married show a gain of 0.5 FIM memory points, as compared to those not married. Additionally each one point increase in admission FIM memory score was associated in an increase of almost 0.5 discharge points. Although statistically significant, age had a small effect, where each 10-year increase in age resulted in a decrease in discharge FIM memory score by approximately 0.2 points.
Table 6.
Regression results
| FIM Memory* | FIM Problem Solving* | FCM Cognitive Composite† | ||||
|---|---|---|---|---|---|---|
|
| ||||||
| Coefficient (95% CI) | P | Coefficient (95% CI) | P | Odds Ratio (95% CI) | P | |
|
| ||||||
| Admission score | 0.475 (0.353–0.596) | .000 | 0.508 (0.370–0.646) | .000 | 3.350 (1.016–11.035) | .047 |
| Age (decile), nonlinear | −0.161 (−0.274 to −0.047) | .006 | −0.202 (−0.328 to −0.077) | .002 | 0.677 (0.477–0.961) | .029 |
| Comorbidity tier | ||||||
| High | −0.007 (−0.521 to 0.508) | .980 | −0.031 (−0.581 to 0.519) | .912 | 22.182 (0.123–3991.868) | .242 |
| Moderate | −0.259 (−0.771 to 0.253) | .318 | −0.103 (−0.649 to 0.443) | .710 | 2.193 (0.189–25.405) | .530 |
| Low | 0.321 (−0.360 to 1.003) | .352 | 0.012 (−0.695 to 0.718) | .974 | 2.341 (0.066–82.657) | .640 |
| Employment status | 0.185 (−0.232 to 0.603) | .382 | 0.099 (−0.352 to 0.551) | .663 | 2.278 (0.174–29.725) | .530 |
| Marital status | 0.663 (0.280–1.046) | .001 | 0.850 (0.410–1.290) | .000 | – | – |
| No. of operations | 0.000 (−0.055 to 0.055) | .990 | −0.018 (−0.076 to 0.041) | .555 | 0.988 (0.638–1.528) | .955 |
| Prehospital living-with | 0.302 (−0.189 to 0.794) | .225 | 0.547 (0.035–1.059) | .036 | – | – |
| TBSA, decile | 0.024 (−0.091 to 0.138) | .682 | 0.053 (−0.069 to 0.175) | .390 | 2.523 (0.905–7.033) | .077 |
FIM, Functional Independence Measure; FCM, Functional Communication Measure; CI, confidence interval.
All significant P values are derived from the final statistical model and are in bold. The data for the nonsignificant variables come from the initial statistical model with all prespecified covariates.
Linear regression.
Logistic regression.
For discharge FIM problem-solving score, significant independent variables were admission FIM problem-solving score, age, marital status, and prehospital living-with (P < .05). TBSA decile, comorbidity tier, number of operations, and employment status were not significant (Table 6). Similar to the results for the FIM memory score, admission FIM problem-solving score and marital status were strongly associated with changes in discharge FIM problem-solving score, while increase in age again resulted in a small decrease in discharge FIM problem-solving score. Interestingly, those who lived alone prior to injury had a gain of 0.6 problem-solving FIM points on discharge. To account for statistical biases, we performed a sensitivity analysis with an ordinal logistic and logistic regression analyzes for both FIM memory and problem-solving scores. The same variables were shown to be significant factors, and our results were qualitatively similar.
Admission FCM cognitive composite score and age were statistically significant (P < .05) in the analysis for discharge FCM score. TBSA decile, comorbidity tier, number of operations, and employment status were not significant (Table 6). With each additional point increase on admission FCM cognitive composite score, odds increase by a multiplier of 3 for an FCM discharge score of at least 5 (ie, modified independent). Age was represented in nonlinear terms. At the lowest ages, increasing age heightens the odds of a discharge score of greater to or equal to 5 (ie, modified independent), but this rate of increase gets slower and plateaus at 55 years old. After 55 years, the odds of achieving a discharge score within this independent range (ie, 5–7) decrease as age increases. Again, to account for potential bias by collapsing the FCM scores into a dichotomous variable, a sensitivity analysis was conducted with linear and ordered logistic regressions. Results were qualitatively similar.
Summary of SLP Intervention Outcomes
A series of t-tests were conducted for the patients who received SLP treatment by comparing the change in mean FIM scores for memory and problem-solving domains, as well as FCM cognitive composite scores from admission to discharge. The mean FIM problem-solving scores increased from 3.96 to 5.7 (P < .0001), the mean FIM memory scores increased from 4.25 to 5.76 (P < .0001), and the mean FCM scores improved from 4.2 to 5.8 (P < .0001). For all three outcome measures, patients who received SLP treatment made functional gains, and many progressed from a dependent level of 4 or below to a more independent level of 5 and above.
Additionally, we compared FIM scores for the domains of memory and problem solving for those with and without SLP intervention by running a series of t-tests, assuming the treated and untreated groups had unequal variances. Most of the patients who did not receive SLP treatment had limited to no change in FIM scores during their rehabilitation course because of their already more independent level scores in these areas on admission. Although the mean increase in FIM scores for the treated group (ie, those receiving SLP intervention) was larger than the untreated groups in each domain, the increases were not statistically significant.
Of note, a total of 31 patients of the total 144 patients studied with low admission FIM problem-solving (25/72) and/or memory (20/72) scores were not referred to SLPs. An additional t-test for patients with low admission FIM memory and problem-solving scores was performed to compare patients who received SLP services to those who did not receive SLP services. The changes in FIM memory scores (P = .07) and FIM problem-solving scores (P = .08) from admission to discharge for patients receiving SLP services vs those not receiving SLP services were not statistically significant. Regarding memory, patients that received SLP treatment (n = 38) achieved a mean change in FIM score of 2.0, while those who did not receive SLP treatment (n=20) had a mean change of 2.6. Problem-solving scores in those who received SLP treatment (n=41) had a mean change of 0.5 and those that did not receive SLP services (n=22) had a mean change of 1.0.
DISCUSSION
This study is the first of its kind to examine the prevalence and extent of cognitive-communication deficits in the burn injury population referred to a regional inpatient rehabilitation facility. As persons with severe burn injuries transition to the rehabilitation phase of their recovery, these additional impairments beyond their critical medical and physical needs become more evident and can have negative impact on rehabilitation outcomes. Cognitive-communication impairments in the areas of attention, memory, and problem-solving skills were identified and ranged in severity from mild to severe. Of the whole burn injury population examined (n = 144), 79% presented with cognitive-communication deficits on admission based on FIM scores of 5 or below. While these patients demonstrate improvements during the course of rehabilitation, 27% of them still present with cognitive-communication deficits on leaving inpatient rehabilitation. Of the patients referred to SLPs, 86% of those evaluated were diagnosed with cognitive-communication deficits and 35% of this subset presented with persistent cognitive impairment at the time of discharge as well, based on FCM discharge scores of 5 or below. Although scores of 5 or above were grouped into the modified independent domain for the purposes of data analysis, those with FCM scores of 5 are still considered to have impairments that would limit their return to vocational activities. These patients would be able to return home with distant supervision for functional problem-solving skills in routine daily activities, but would likely be referred for SLP follow-up on discharge in order to treat higher level cognitive skills necessary for regaining full function and returning to premorbid responsibilities.
Cognitive impairments identified in other rehabilitation populations have been shown to have impact on rehabilitation success and functional outcomes. Elderly patients receiving rehabilitation following a hip fracture with higher cognitive FIM scores on admission were associated with shorter lengths of stay and greater rehabilitation outcomes.17 In the stroke population, patients with cognitive impairments in addition to physical deficits show less recovery of physical function18,19 and greater dependency in living after their stroke.20,21 Poorer long-term outcomes are also observed in a sample of patients following stroke with relatively moderate cognitive deficits. While cognitive impairment did not appear to predict recovery of basic self-care tasks, cognitively impaired patients had poorer recovery of instrumental activities of daily living tasks, which involve higher order cognitive skills, at 6 month follow-up.22
Another aim of our study was to determine the impact of medical, demographic, and rehabilitation factors on outcomes of patients with burn injuries. This objective was essential in order to better understand which patients are at higher risk for experiencing limitations in rehabilitation due, at least in part, to persisting cognitive-communication deficits. Patients rated with lower admission FIM memory and problem-solving and FCM cognitive composite scores are more likely to have worse outcomes in these areas on discharge. Therefore, the admission FIM memory and problem-solving score may be a useful and reliable screening tool to identify patients at risk of persistent cognitive deficits that may affect their overall rehabilitation outcomes and return to premorbid level of functioning.
Interestingly, 31 of 72 patients (43%) were identified as at-risk, given low admission FIM cognitive scores in the domains of memory and/or problem solving, though were not referred for SLP evaluation. These deficits may have been underappreciated, and our data highlight the need for consistent SLP referrals, particularly for these patients with low admission FIM cognitive scores. SLP referrals for these at-risk patients may be the most effective and efficient way to assess if cognitive-communication deficits are present and may serve as a new standard of care in this population. As a result of these findings, our Burn Injury Program admission process expanded to include SLP referrals for all patients with burn injuries and/or use admission FIM scores as a screening tool based on ratings from other disciplines to expedite referral to SLPs.
Furthermore, those who are married and/or younger in age are more likely to achieve greater gains in cognitive-communication function. This gain may be due to the spouse’s role in facilitating carryover of strategies and retention of new information outside of therapy time. The role of social ties has been studied in the stroke population, and emotional support was found to yield greater cognitive recovery.23
Our results indicate that persons who lived alone prior to injury demonstrated a gain of 0.6 FIM points in problem solving on discharge. We hypothesize this finding could be related to any number or combination of factors including: being accustomed to solving problems without assistance from a partner premorbidly, having a longer length of stay in order to meet their goal of safely returning home alone, higher baseline level of functioning, or age. Further investigation into this finding would be an important future study to provide more information about this population.
It was hypothesized that the variables of TBSA, presence of head and neck burns, history of ventilation, history of tracheostomy, and number of operations would be significant predictors of cognitive outcomes. However, the results of this study did not confirm this hypothesis. Our findings are consistent with Slocum et al, who also report that these complex comorbidities were not significant in predicting overall general rehabilitation outcomes.24
A secondary aim of our study was to examine patients’ cognitive-communication outcomes following SLP intervention. Identification and treatment of cognitive-linguistic disorders is a primary area of practice for SLPs. They possess expertise in these areas and serve an important and integral role on the burn care team to treat these deficits directly as well as assist with identifying and planning for needs after discharge. Skilled SLP intervention instructs persons in use of strategies to improve and/or compensate for cognitive-communication deficits to more independently function and reduce the incidence of employing maladaptive or inefficient approaches.5,7,25 Our findings indicate a significant increase in FCM cognitive scores and FIM memory and problem solving following SLP treatment. This improvement in FCM and FIM scores importantly highlights gains in functional status, as mean scores improved from an admission score of 4 or below, indicating a level of dependency, to a discharge score of 5 which can be considered modified independence. Although persons functioning at a modified independent level may be able to live alone, they may still experience difficulty functioning at a more complex level such as performance within a work setting.16 Based on this preliminary retrospective investigation, patients who did not receive SLP services demonstrated statistically similar gains when compared to the SLP treatment group in terms of FIM scores from admission to discharge. It is important to note however that subjects were not randomized and variables such as type, frequency, and duration of SLP treatment were not controlled for because of the retrospective nature of this study. Controlling these factors may have resulted in different results. Further prospective research focused on treatment approaches and outcomes is warranted to determine the impact of SLP intervention on cognitive-communication outcomes in this population.
Limitations of this study include the small sample size of patients with burn injury and even smaller number of patients with available FCM data to more finely and robustly illustrate the cognitive-communication profiles of those treated by SLPs. This study examines only the burn population and outcomes in the IRF setting. It would be interesting to examine the outcomes of the burn population with cognitive-communication impairments across all settings (eg, acute, subacute, home, outpatient, etc.). Length of stay in the acute inpatient rehabilitation setting was not analyzed, which could also be an important factor in FIM and/or FCM outcomes or an interesting outcome measure. The analysis used in this study examines the association of independent variables to the outcome measures; therefore, causality cannot be concluded from the data.
Furthermore, although more definitive information regarding possible etiologies and factors contributing to the development of cognitive deficits as a consequence of burn injury is of great interest, these variables also are not readily accessible within our current reporting and documentation systems. Data such as hypoxia, length of intubation, inhalation injury, and presence of acute respiratory distress syndrome can provide a better understanding of why some patients demonstrate cognitive deficits. However, this information is difficult to obtain as they are not uniformly collected as part of the NIDRR database. Furthermore, they are not readily and objectively searchable via our electronic and/or paper medical records because of variations in clinician coding and range of definitions associated with these terms. Our preliminary study, being a retrospective analysis, did not allow us to control for many of these variables, but it does lay important groundwork. Future prospective studies are needed to further tease out and identify possible factors that could account for or contribute to cognitive deficits in this population.
Further limitations are also related to the quality and quantity of FCM data collected. FCM data points were lost because of inaccessible electronic medical records. Additionally, accessible FCM ratings were not consistently documented at both admission and discharge, which resulted in some incomplete data sets. Consistent use of the FCM ratings on admission and discharge for all treatment domains would yield a more complete data set for future analysis and study.
Nevertheless, this study is the first to document the prevalence and extent of cognitive-communication deficits in the burn injury population that persist during the acute rehabilitation course and establish the foundation for further research. These research findings make important contributions to the burn literature that can be implemented within clinical practice to positively affect patient performance, quality of life, and outcomes.
CONCLUSIONS
Preliminary evidence indicates that persons with burn injuries are at risk for cognitive-communication deficits early after injury that could interfere with the effectiveness of inpatient rehabilitation and functional outcomes. These cognitive-communication deficits can persist after discharge from IRF and affect a person’s ability to resume premorbid activities at home, in the community, and in vocational settings. The cognitive FIM admission ratings can be used as a screening tool to identify these at-risk patients and make appropriate referrals. Earlier and consistent referral to SLPs for evaluation, treatment, and discharge planning may further benefit this population.
ACKNOWLEDGMENTS
We would like to acknowledge Douglas Geiger, MS CCC-SLP, and Deidre Viau BA of Spaulding Rehabilitation Hospital for their assistance with data collection, as well as Jennifer Mello, MS CCC-SLP, of Massachusetts General Hospital for her clinical expertise with the acute inpatient burn population.
The contents of this study were developed under a grant from the Department of Education, NIDRR grant number H133A120034. However, these contents do not necessarily represent the policy of the Department of Education, and the reader should not assume endorsement by the Federal Government.
REFERENCES
- 1.Ryan CM, Schoenfeld DA, Thorpe WP, Sheridan RL, Cassem EH, Tompkins RG. Objective estimates of the probability of death from burn injuries. N Engl J Med 1998;338:362–6. [DOI] [PubMed] [Google Scholar]
- 2.Tan WH, Goldstein R, Gerrard P, et al. Outcomes and predictors in burn rehabilitation. J Burn Care Res. 2013;34:666–73. [DOI] [PubMed] [Google Scholar]
- 3.Purohit M, Goldstein R, Nadler D, et al. Cognition in patients with burn injury in the inpatient rehabilitation population. Arch Phys Med Rehabil 2014;95:1342–9. [DOI] [PubMed] [Google Scholar]
- 4.American Speech-Language-Hearing Association. Roles of speech-language pathologists in the identification, diagnosis, and treatment of individuals with cognitive-communication disorders: position statement [Position Statement]. 2005; available from www.asha.org/policy; accessed 12 Aug. 2014. [Google Scholar]
- 5.American Speech-Language-Hearing Association. Scope of practice in speech-language pathology [Scope of Practice]. 2007; available from www.asha.org/policy; accessed 12 Aug. 2014.
- 6.World Health Organization. International classification of functioning, disability and health (ICF). Geneva, Switzerland: World Health Organization; 2001. [Google Scholar]
- 7.American Speech-Language-Hearing Association. Preferred practice patterns for the profession of speech-language pathology. Rockville, MD: American Speech-Language-Hearing Association; 1997. [Google Scholar]
- 8.Wolters AE, Slooter AJ, van der Kooi AW, van Dijk D. Cognitive impairment after intensive care unit admission: a systematic review. Intensive Care Med 2013;39:376–86. [DOI] [PubMed] [Google Scholar]
- 9.Whyte E, Skidmore E, Aizenstein H, Ricker J, Butters M. Cognitive impairment in acquired brain injury: a predictor of rehabilitation outcomes and an opportunity for novel interventions. PM R 2011;3(6 Suppl 1):S45–51. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Tan WH, Goldstein R, Gerrard P, et al. Outcomes and predictors in burn rehabilitation. J Burn Care Res 2012;33:110–7. [DOI] [PubMed] [Google Scholar]
- 11.UB Foundation Activities, Inc. Uniform data system for medical rehabilitation: IRF-PAI training manual. Buffalo, NY: University at Buffalo Foundation, Inc., 2004; available from https://www.cms.gov/Medicare/Medicare-Feefor-Service-Payment/InpatientRehabFacPPS/downloads/irfpaimanual040104.pdf; accessed 8 Nov. 2015. [Google Scholar]
- 12.Rumbach AF, Ward EC, Cornwell PL, Bassett LV, Khan A, Muller MJ. Incidence and predictive factors for dysphagia after thermal burn injury: a prospective cohort study. J Burn Care Res 2011;32:608–16. [DOI] [PubMed] [Google Scholar]
- 13.State University of New York at Buffalo. Guide for the Uniform Data Set for Medical Rehabilitation (including the FIM™ instrument), Version 5.1. Buffalo, NY: State University of New York at Buffalo; 1997. [Google Scholar]
- 14.Cournan M Use of the functional independence measure for outcomes measurement in acute inpatient rehabilitation. Rehabil Nurs 2011;36:111–7. [DOI] [PubMed] [Google Scholar]
- 15.Gerrard P, Goldstein R, Divita MA, et al. Validity and reliability of the FIM instrument in the inpatient burn rehabilitation population. Arch Phys Med Rehabil 2013;94:1521–6. [DOI] [PubMed] [Google Scholar]
- 16.American Speech-Language-Hearing Association. National Outcomes Measurement System (NOMS): adult speech-language pathology user’s guide. Rockville, MD: American Speech-Language-Hearing Association; 2003. [Google Scholar]
- 17.Heruti RJ, Lusky A, Barell V, Ohry A, Adunsky A. Cognitive status at admission: does it affect the rehabilitation outcome of elderly patients with hip fracture? Arch Phys Med Rehabil 1999;80:432–6. [DOI] [PubMed] [Google Scholar]
- 18.Mysiw WJ, Beegan JG, Gatens PF. Prospective cognitive assessment of stroke patients before inpatient rehabilitation. The relationship of the Neurobehavioral Cognitive Status Examination to functional improvement. Am J Phys Med Rehabil 1989;68:168–71. [DOI] [PubMed] [Google Scholar]
- 19.Paolucci S, Antonucci G, Gialloreti LE, et al. Predicting stroke inpatient rehabilitation outcome: the prominent role of neuropsychological disorders. Eur Neurol 1996;36:385–90. [DOI] [PubMed] [Google Scholar]
- 20.Pohjasvaara T, Erkinjuntti T, Vataja R, Kaste M. Correlates of dependent living 3 months after ischemic stroke. Cerebrovasc Dis 1998;8:259–66. [DOI] [PubMed] [Google Scholar]
- 21.Grimby G, Andrén E, Daving Y, Wright B. Dependence and perceived difficulty in daily activities in community-living stroke survivors 2 years after stroke: a study of instrumental structures. Stroke 1998;29:1843–9. [DOI] [PubMed] [Google Scholar]
- 22.Zinn S, Dudley TK, Bosworth HB, Hoenig HM, Duncan PW, Horner RD. The effect of poststroke cognitive impairment on rehabilitation process and functional outcome. Arch Phys Med Rehabil 2004;85:1084–90. [DOI] [PubMed] [Google Scholar]
- 23.Glymour MM, Weuve J, Fay ME, Glass T, Berkman LF. Social ties and cognitive recovery after stroke: does social integration promote cognitive resilience? Neuroepidemiology 2008;31:10–20. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Slocum CS, Goldstein R, DiVita MA, et al. Assessing the ability of comorbidity indexes to capture comorbid disease in the inpatient rehabilitation burn injury population. Am J Phys Med Rehabil 2015;94:373–84. [DOI] [PubMed] [Google Scholar]
- 25.Cicerone KD, Langenbahn DM, Braden C, et al. Evidence-based cognitive rehabilitation: updated review of the literature from 2003 through 2008. Arch Phys Med Rehabil 2011;92:519–30. [DOI] [PubMed] [Google Scholar]