Age
In the coming decades, demographic changes will result in a significant increase in the proportion of older individuals all over the globe. For example, in Canada, it is estimated that seniors will account for 30% of the population by 2068, an increase of 17% from 2018 (Statistics Canada 2019). When considering epidemiological evidence that found the highest rates of SCI-related hospital admission following trauma in Ontario, Canada was for those over 70 years of age, this has significant implications for the delivery of rehabilitation and support services to this group of patients (Pickett et al. 2006). In addition, many centers in various places around the world provide rehabilitation services to individuals with spinal cord damage as the result of a variety of non-traumatic etiologies and often these people are much older than those injured due to trauma (McKinley et al. 2001; McKinley et al. 2002; New 2005; Scivoletto et al. 2003). Given these trends, it is important to understand the effects of age on rehabilitation outcomes. Several studies have investigated age as an interventional trait to identify which individuals may have better rehabilitation outcomes.
Author Year; Country |
Methods |
Outcome |
Franceschini et al. 2020; Switzerland |
Population: Mean age=50±20yr; Gender: male=402, female=95, Level of injury: not reported; Severity of injury: AIS A=173, B=78, C=122, D=104, E=2. Intervention: No intervention. Prospective analysis of patient characteristics on functional gains and discharge destination in patients with SCI admitted to rehabilitation. Outcome measures: SCIM |
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Furlan & Fehlings 2009; Canada |
Population: Younger Individuals (<65yr; n=455): Mean age=31.9yr; Gender: males=82.9%, females=17.1%; Level of injury: cervical=65.6%, thoracolumbar=24.4%; Severity of injury: complete=51.9%, incomplete=48.1%; Time since injury=not reported. Older Individuals (>65yr; n=44): Mean age=75yr; Gender: male=92.7%, female=7.3%; Level of injury: cervical=89.5%, thoracolumbar=10.5%; Severity of Injury: complete=29.5%, incomplete=70.5%; Time since injury=not reported. Intervention: No intervention. Prospective observational analysis of the impact of age on mortality, impairment and disability among adults with acute traumatic SCI. Outcome measures were assessed at 6wk, 6mo and 12mo. Outcome Measures: Mortality, FIM. |
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Osterthun et al. 2009; Netherlands |
Population: Traumatic SCI: Mean age=43.4yr; Gender: male:female=2.8:1; Level of injury: tetraplegia=49.6%; Severity of injury: complete=52.3%; Non-traumatic SCI: Mean age=57.2yr; Gender: male:female=1.2:1; Level of injury: tetraplegia=24.2%; Severity of injury: complete=25.9% Intervention: No intervention. Those with traumatic SCI were compared to those with non-traumatic SCI. Outcome Measures: Functional status, LOS. |
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Gupta et al. 2008; India |
Population: Traumatic (n=38): Mean age=32.86yr; Gender: males=34, females=4. Non-traumatic (n=38): Mean age=31.10; Gender: males=16, females=22 Intervention: Admission/discharge data from all surviving non-traumatic and traumatic spinal cord lesion (SCL) patients in a neurological rehabilitation facility was assessed over a 2yr period. Outcome Measures: Length of stay; AIS collected at admission and discharge. |
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McKinley et al. 2008; USA |
Population: Infection related spinal cord disease (IR-SCD): Mean age=53.3yr; Gender: males=64.7%; Level of injury: paraplegia=74%. Traumatic SCI: Mean age=40.4yr; Gender: males=83.8%; Level of injury: paraplegia=49% Intervention: No intervention. Data was reviewed of individuals diagnosed with infection related SCD against those with traumatic SCI. Outcome Measures: Acute and rehabilitation hospital LOS, FIM motor scores, FIM motor change, FIM motor efficiency, AIS change. |
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Tchvaloon et al. 2008; Israel |
Population: Mean age=37.8yr; Gender: M:F=4.95:1; Level of injury: C=43%, T=49.3%, L=7.7%; Severity of injury: complete=41%, incomplete=59%. Intervention: No intervention. Data from patients with a SCI due to a road accident was analyzed. Outcome Measures: Neurological recovery, Functional recovery, complications. |
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Anzai et al. 2006; Canada |
Population: Mean age=45.3yr; Gender: males=77%, females=23%; Level of injury: C4=63%; Severity of Injury: AIS A=60% Intervention: No intervention. Retrospective chart review was conducted on patients admitted to GF Strong Spinal Cord Program between 1994 and 2003. Outcome Measures: Discharge destination, factors associated with discharge to ECU. |
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New et al. 2005; Australia |
Population: Non-traumatic SCI: Mean age=69yr; Level and severity of injury: AIS B-D, tetraplegia=32.9%, AIS A, paraplegia=8.6%, AIS B-D=58.6%; Time since injury: <7 days=78.6%; Time to rehabilitation=30.9 days. Intervention: No intervention. Outcomes associated with non-traumatic SCI rehabilitation were assessed. Outcome Measures: Demographics, clinical characteristics, LOS, Discharge setting, level of lesion and AIS, FIM, mobility, bowel and bladder function. Collected at admission to and discharge from rehabilitation. |
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Ronen et al. 2004; Israel |
Population: Traumatic Spinal Cord Injury (TSCI; n=250): Mean age=34.5±15.3yr; Gender: males=5, females=0; Level of injury: cervical=37%. Thoracic=32%, lumbosacral=31%; Severity of injury: Frankel grade A=74, B=42, C=100, D=34; Time since injury=59 days.
Non-Traumatic Spinal Cord Injury (NTSCI; n=1117): Mean age=47.1±16.8yr; Gender: male=9, female=3; Level of injury: cervical=32%, thoracic=44%, lumbosacral=24%; Severity of Injury: Frankel grade A=32, B=146, C=506, D=433. Time since injury=51mo. |
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Pollard & Apple 2003; USA |
Population: Mean age=not reported; Gender: not reported; Level and severity of injury: incomplete tetraplegia; Time since injury=not reported. Intervention: No intervention. Retrospective review of patients with incomplete tetraplegia to determine what patient characteristics, injury variables and management strategies are associated with improved neurological outcomes. Outcome Measures: Motor score, motor level sensory score, sensory level and ASIA grade. |
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Kennedy et al. 2003; UK |
Population: Traumatic and non-traumatic SCI: Mean age=40.7yr; Gender: males=147, females=45; Level and severity of injury: incomplete tetraplegia=23%, complete tetraplegia=21%, complete paraplegia=34%, incomplete paraplegia=22; Mean time post-injury to admission=28.8 days. Intervention: No intervention. Various outcomes associated with inpatient rehabilitation focusing on goal attainment in younger versus older patients. Outcome Measures: Needs Assessment Checklist (NAC) collected within 2wk of mobilization and within 6wk of discharge. |
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Scivoletto et al. 2003; Italy |
Population: Mean age=50.4yr; Gender: males=184, females=100; Level of injury: cervical=81, thoracic=148, lumbosacral=55; Severity of injury: AIS: A-D; Mean time post-lesion to admission=56.9 days. Intervention: No intervention. Various outcomes associated with inpatient rehabilitation focusing on younger (<50) versus older (>50) patients. Mean LOS was 98.7±68.1 days. Outcome Measures: LOS, AIS, ASIA Motor Index, BI, Rivermead Mobility Index (RMI), Walking Index for SCI (WISCI), Discharge Destination. All collected at admission and discharge. |
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McKinley et al. 2002; USA |
Population: Non-traumatic SCI secondary to stenosis (n=81) versus traumatic SCI (n=102) within a single centre; Matching from N=381 sample on paraplegia versus tetraplegia and completeness. Intervention: No intervention. Various outcomes associated with non-traumatic (stenosis) versus traumatic SCI rehabilitation were compared. Outcome measures were collected at admission to and discharge from rehabilitation. Outcome Measures: LOS, charges, Discharge rates to home, FIM (score, change and efficiency). |
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Seel et al. 2001; USA |
Population: Traumatic SCI from United States Model Systems database: Gender: male, female, three equal (N=60) age groups (18-39, 40-59, >59) matched for neurological level and ASIA classification, paraplegia, AIS A-D, 84% admitted within 21 days post-injury. Intervention: No intervention. Various outcomes associated with inpatient acute and rehabilitation care focusing on age effects by comparing results between three age categories. Outcome Measures: LOS, Charges, ASIA motor index score, FIM, change scores and efficiencies for FIM. All collected at admission to acute care and admission to rehabilitation care and discharge. |
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Van der Putten et al. 2001; Netherlands |
Population: Non-traumatic SCI: mean age=55yr; Gender: male=54%; Level of injury: cervical=49%, upper thoracic=21%, lower thoracic and lumbar=22%; Time from onset to rehabilitation=4.8yr. Intervention: No intervention. Optimal outcomes were regressed against various factors associated with non-traumatic rehabilitation. Outcome Measures: Demographics, clinical characteristics, level of lesion and AIS, FIM motor score and change score. Collected at admission to and discharge from rehabilitation. |
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Eastwood et al. 1999; USA |
Population: Age: <21=882, 21-30=1182, 31-40=803, 41-50=484, >50=552, unknown=1; Gender: males=3157, females=747; Level and severity of injury: paraplegia-incomplete=777, paraplegia-complete=1202, tetraplegia-incomplete=1065, tetraplegia-complete=782, unknown=78; Time since injury=not reported. Intervention: No intervention. Retrospective chart review of patients discharged between 1990 and 1997 with traumatic SCI to determine predictors of acute rehabilitation length of stay and their association with medical and social outcomes. Outcomes were assessed at rehabilitation discharge and one yr following injury. Outcome Measures: Rehabilitation LOS, age, race, method of bladder management, tetraplegia, education, marital status, discharge disposition, one-year presence of pressure ulcers, rehospitalization, place of residence, days per week out of residence. |
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Cifu et al. 1999; USA |
Population: Traumatic SCI from United States Model Systems database: Gender: male and female, three equal (N=125) age groups (18-34, 35-64, >64) matched for neurological level and completeness, tetraplegia, AIS A-D, 85% admitted within 21 days post-injury. Intervention: No intervention. Various outcomes associated with inpatient acute and rehabilitation care focusing on age effects by comparing results between three age categories. Outcome Measures: LOS, Charges, ASIA motor index score, FIM, change scores and efficiencies for FIM and ASIA motor index, Discharge destination. All collected at admission to acute care and admission to rehabilitation care and discharge. |
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Cifu et al. 1999; USA |
Population: Traumatic SCI from United States Model Systems database: Mean age =31.72yr; Gender: males =83%, females =17%; Level of injury: paraplegia; Severity of injury: AIS: A-D. Intervention: No intervention. Various outcomes associated with inpatient acute and rehabilitation care focusing on age effects by comparing results between 11 age categories. Mean acute LOS was 13.2±16.92 days. Mean rehabilitation LOS was 56.76±34.28 days. Outcome Measures: LOS, Charges, ASIA motor index score, FIM, change scores and efficiencies for FIM and ASIA motor index. All collected at admission to acute care and admission to rehabilitation care and discharge. |
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McKinley et al. 1999; USA |
Population: Non-traumatic SCI secondary to neoplastic cord compression admitted over 5 years (within a single centre (n=29) versus traumatic SCI (n=29) from the United States Model Systems database matched by age, level of injury and AIS; Age =57.8 years; AIS A-D; C4-L2. Intervention: No intervention. Various outcomes associated with rehabilitation care of non-traumatic (neoplastic cord compression) versus traumatic SCI. Outcome measures were collected at admission to and discharge from rehabilitation. Outcome Measures: LOS, Discharge destination, FIM (total score, change and efficiency). |
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Devivo et al. 1990; USA |
Population: Group 1 (Age=1-15yr): Gender: males=80%, females=20%; Level of injury: paraplegia=47.5%, tetraplegia 52.5%; Severity of injury: complete=52.5%, incomplete=47.5%; Time since injury=not reported. Group 2 (Age=16-30yr): Gender: males=84.6%, females=15.4%; Level of injury: paraplegia=52.1%, tetraplegia=47.9%; Severity of injury: complete=55%, incomplete=45%; Time since injury=not reported. Group 3 (Age=31-45yr): Gender: males=81.1%, females=18.9%; Level of injury: paraplegia=52%, tetraplegia =48%; Severity of injury: complete=45.9%, incomplete=54.1%; Time since injury=not reported. Group 4 (Age=46-60yr): Gender: males=79%, females=21%; Level of injury: paraplegia=46%, tetraplegia=54%; Severity of injury: complete=43%%, incomplete=57%; Time since injury=not reported. Group 5 (Age=61-86yr): Gender: males=70%, females=30%; Level of injury: paraplegia=28.6%, tetraplegia 71.4%; Severity of injury: complete=36.2%, incomplete=63.8%; Time since injury=not reported. Intervention: No intervention. Patients were retrospectively divided into five age groups: Group 1 (1-15yr), Group 2 (16-30yr), Group 3 (31-45yr), Group 4 (46-60yr), Group 5 (61-86yr). Data was then used to assess the effects of age on rehabilitation outcome. Outcome Measures: Relationship of age with clinical outcomes. |
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Yarkony et al. 1988; USA |
Population: Traumatic SCI: Mean age=28.3yr; Gender: males=82%, females=18%; Level and severity of injury: complete paraplegia=30%, incomplete paraplegia=15%, complete tetraplegia=27%, incomplete tetraplegia=28%. Intervention: No intervention. Patients were retrospectively divided into four groups: Group 1 (6-19yr), Group 2 (20-39yr), Group 3 (40-59yr), Group 4 (60-88yr) and data was analyzed. Outcome Measures: Relationship of age to clinical outcomes. |
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Similar approaches involving case control study designs have been employed by various investigators to examine the effect of age on rehabilitation outcomes. However, in the present review, studies employing some form of matching across different age groups were assessed as representing a higher level of evidence (Cifu et al. 1999; DeVivo et al. 1990; Scivoletto et al. 2003; Seel et al. 2001; Yarkony et al. 1988) as compared to those deemed as having an inadequate method of controlling for potential confounds (Cifu et al. 1999; Kennedy et al. 2003). Several of these studies have demonstrated differences between age groups for a variety of rehabilitation outcomes although there were also some contradictory findings within these studies, albeit some of this may have been due to variation between the sampling frames and methods employed in each study.
For example, Seel et al. (2001) and Cifu et al. (1999) reported reduced rehabilitation LOS for those with paraplegia due to trauma or mixed etiology Osterthun et al. (2009) whereas no differences were seen in investigations of those with tetraplegia due to trauma (Cifu et al. 1999) and also with the mixed sample of people with both traumatic and non-traumatic SCI (Ronen et al. 2004; Scivoletto et al. 2003).
Yarkony et al. (1988) were the first to look at the independent effect of age on rehabilitation outcomes in SCI. This study found that functional outcome was only related to age in patients with complete paraplegia. Among these individuals, Yarkony et al. (1988) demonstrated a trend between the increase in age and increased dependence on seven functional skills including bathing, upper and lower body dressing, stair climbing, and transfers to a chair, toilet, and bath. Yarkony attributed this trend to the fact that there is a “greater residual muscle function” in these individuals. Devivo et al. (1990) later supported this trend by demonstrating an inverse relationship between patients’ age and their level of independence in self-care activities. Anzai et al. (2006) and Eastwood et al. (1999) reported that older individuals were at increased risk of being discharged to an extended care facility due to pre-existing co-morbidities and lack of social and financial support. Similarly, New et al. (2005) reported that younger individuals were more likely to be discharged home.
Conversely, all studies examining functional change showed that younger individuals demonstrated greater functional improvements as indicated by increases in the FIM (i.e., motor FIM scores, change scores, efficiencies) (Cifu et al. 1999; Cifu et al. 1999; Furlan & Fehlings 2009; Pollard & Apple 2003; Seel et al. 2001; van der Putten et al. 2001), BI (Scivoletto et al. 2003) or SCIM (Franceschini et al. 2020). These similar results were obtained from studies involving those with paraplegia (Cifu et al. 1999; Seel et al. 2001), tetraplegia (Cifu et al. 1999), and a mixed sample comprised of those with both traumatic and non-traumatic SCI (Scivoletto et al. 2003). On the other hand, Kennedy et al. (2003) employed the Needs Assessment Checklist developed internally at Stoke-Mandeville, United Kingdom, and demonstrated that there were few systematic age-related differences associated with goal attainment in a mixed traumatic, non-traumatic sample. The Needs Assessment Checklist is a client-focused outcome measure that assesses the degree to which specific behavioural outcomes particularly relevant to the client are achieved. Tchvaloon et al. (2008) (N=143) also reported no significant effect on recovery due to age at injury in an Israeli population of people with traumatic SCI.
In addition to functional outcomes, effective rehabilitation has also been associated with increases in neurological status as indicated by AIS or ASIA motor scores. Of the studies reviewed and utilizing measures of neurological status, both studies limited to those with paraplegia and showed no age effects (Cifu et al. 1999; Seel et al. 2001). Conversely, similar studies of those with tetraplegia or a mixed traumatic and non-traumatic SCI sample demonstrated that younger individuals were more likely to make significant neurological gains during inpatient rehabilitation (Cifu et al. 1999; Scivoletto et al. 2003). Additionally, conflicting findings exist in relation to the mechanism of injury with Gupta and colleagues (2008) reporting that traumatic versus non-traumatic injuries are not associated with age. Conversely, McKinley et al. (2008; 1999; 2002) found that non-traumatic injuries are significantly associated with older age.
Despite mixed research regarding the impact of age on SCI rehabilitation, it is reasonable to assume that older individuals require individualized care. In light of this, guidelines established by Rapidi and colleagues (2018) suggest that therapeutic exercise programs in SCI should be prescribed and adapted to each individual’s needs, according to the neurological level of injury, age, and comorbidities.
Conclusions
There is level 3 evidence (from four case control studies: Cifu et al. 1999; Cifu et al. 1999; Osterthun et al. 2009; Seel et al. 2001) that shorter rehabilitation LOS is associated with younger versus older individuals with paraplegia. The same may not be true for those with tetraplegia or for mixed cohorts involving traumatic and non-traumatic SCI.
There is level 3 evidence (from four case control studies: DeVivo et al. 1990; Kennedy et al. 2003; Scivoletto et al. 2003; Yarkony et al. 1988; and one observational study: Franceschini et al. 2020) that age is inversely related to patient’s independence level.
There is level 3 evidence (from five case control studies: Cifu et al. 1999; Cifu et al. 1999; Kennedy et al. 2003; Scivoletto et al. 2003; Seel et al. 2001) that younger as compared to older individuals are more likely to obtain greater functional benefits during rehabilitation.
There is level 3 evidence (from two case control studies: Kennedy et al. 2003; Scivoletto et al. 2003) that significant increases in neurological status during rehabilitation are more likely with younger than older individuals with tetraplegia or for mixed cohorts involving traumatic and non-traumatic SCI. The same may not be true for those with paraplegia.
There is conflicting level 3 evidence (from three case control studies: Gupta et al. 2008; McKinley et al. 1999; McKinley et al. 2002) that older individuals are more likely to experience a non-traumatic than traumatic SCI.
There is level 4 evidence (from one case series: Tchvaloon et al. 2008) that older individuals are more at risk of developing pressure sores.
There is level 4 evidence (from two case series: Anzai et al. 2006; New 2005) that older individuals are more likely to be discharged to an extended care unit.
There is level 4 evidence (from one case series: Eastwood et al. 1999) that age may be associated with a longer length of rehabilitation stay.
There is level 4 and 5 evidence (from two case series and one observational study: Furlan & Fehlings 2009; Pollard & Apple 2003; van der Putten et al. 2001) that younger patients are more likely to experience improved motor outcomes when compared to older individuals. However, both groups experience similar sensory deficits.
There is level 5 evidence (from one observational study: Ronen et al. 2004) that age has no effect on the length of acute hospital stay.