Barriers to rehabilitation participation beyond motivation

Beyond Motivation
March 28, 2014

Nancy Hansen Merbitz, PhD
Clinical Assistant Professor
Department of PM&R
University of Michigan
The planners, editors and faculty of this activity
have no relevant financial relationships to
disclose.

Learning Objectives
At the conclusion of this course participants will be able to:
 Describe a variety of medically-related causal factors that can
overlap and have cumulative effects on behavior, emotions,
thoughts and cognitive abilities
 Distinguish that medical and psychological factors are not
“either-or”
 Identify that a patient’s ability to follow through with goal-
directed behavior arises from the highest levels of brain
function and can easily be disrupted by factors separate from
the person’s baseline personality & desire to get better

To obtain credit you must:
– Be present for the entire session
– Complete an evaluation form
– Return the evaluation form to staff
Certificate will be sent to you by e-mail.
Rush designates this live activity for 1 (one) AMA PRA Category 1 Credit™
Rush University Medical Center is accredited by the Accreditation Council for Continuing Medical
Education to provide continuing medical education for physicians.
Rush University (OH-390, 8/25/2014) is an approved provider of continuing education by the Ohio
Nurses Association (OBN-001-91), an accredited approver by the American Nurses Credentialing
Center’s Commission on Accreditation. Rush University designates this live activity for one (1)
Continuing Education contact hour(s).
Rush University is an approved provider for physical therapy, occupational therapy, respiratory therapy,
social work, nutrition, speech-audiology, and psychology by the Illinois Department of Professional
Regulation. Rush University designates this live activity for one (1) Continuing Education credit(s).

Many rehab inpatients come from critical care
 Growing evidence of persisting cognitive
impairments after critical illness (e.g. ARDS, sepsis)
 Pandharipande, P. P., et al. "Long-term cognitive impairment
after critical illness." New England Journal of Medicine
369.14 (2013): 1306-1316.
 Iwashyna TJ, Ely EW, Smith DM, Langa KM. Long-term
Cognitive Impairment and Functional Disability Among
Survivors of Severe Sepsis. JAMA 2010; 304(16): 1787-1794.

Many rehab inpatients come from critical care…
 Growing evidence of persisting emotional
impairment after critical illness (e.g. depression;
anxiety, PTSD)
 Davydow, Dimitry S., et al. "Psychiatric morbidity in survivors
of the acute respiratory distress syndrome: a systematic
review." Psychosomatic medicine 70.4 (2008): 512-519.
 De Miranda S, Pochard F, Chaize M, et al: Postintensive care
unit psychological burden in patients with chronic
obstructive pulmonary disease and informal caregivers: A
multicenter study. Crit Care Med 2011; 39:112-118.

Impact of prior critical care
 These experiences have lingering effects on their
participation in rehabilitation.
 Arousal, alertness
 Trust
 Mood, emotional regulation
 Cognition: Orientation and new learning abilities
 This may give rise to questions about their
motivation for rehab.

How do we think about “motivation”?
 There is a human tendency to lapse into tautology
regarding explanations of behavior:
 “If the patient did something, he was motivated to do it.
If he didn’t do something, he was unmotivated to do it.”
 Interestingly, we are less likely to explain our OWN
behavior in this way.

A consistent finding from
Social Psychology research
re our perceptions of
less-than-optimal behavior is:
the “Fundamental Attribution
Error”.

The Fundamental Attribution Error
 When I do something (or fail to do something), it’s
due to circumstantial factors, such as “I was tired. I
was stressed by others. I have too much going on. I
didn’t get enough sleep.”

The Fundamental Attribution Error
 When someone else does something (or fails to do
something), it is because of his or her motivation.
 i.e. various internal factors such as mood, fear, lack of
determination, avoidance, poor work ethic, etc.
 These may or may not be relevant in a particular case, but
the point is, we infer these internal psych factors re:
OTHERS’ behavior more than we do re: our own behavior.

 Of course our patients do come to us with many
psychological factors influencing their behavior.
 Their previous personal history converges with their
current struggles with dependence and vulnerability,
 and most of this takes place in connection with a team
of people, formerly strangers, who in many respects
become more intimate than family.
 This is powerful stuff, which has a great impact on
behavior during rehabilitation and beyond.
 But today I want to point you toward some factors that
are closer to the traditional medical bailiwick, but which
can present as problems of “motivation”.

Main ideas for today: #1
 The effects of medical conditions, medications,
hospitalization, pain, and sleep deprivation on brain
functioning can fall far short of “delirium”,
 presenting instead as problems with energy, mood, new
learning and recall, emotional self-regulation and
maturity of coping.
 As one pt put it, “It’s like I’m going to therapies
with my brain tied behind my back.”

#2
 Acute rehabilitation provides a unique, extended
opportunity to observe behavior (broadly defined
to include learning, moving, interacting with others,
expressing emotions) in an environment that is
both challenging and supportive.

#3
 Viewing problems of behavior as problems in
“motivation” may cause us to miss opportunities to
improve what we are doing and get better
outcomes.
 It may lead to overtreatment with psychotropic
medications.

#4

 Conversely, viewing behavior over time, as a
phenomena in itself, may allow us to discover and
correct barriers to optimal functioning, medical or
environmental.

Rehab patients’ medical and psychological
experiences are intertwined, not either/or
 May have had a long hx of medical problems
 With many prior setbacks, struggling to cope w/ decline
 May have had an unusual disorder that wasn’t
diagnosed for years,
 while the pt worried about his/her credibility in reporting
symptoms.
 May have distrust, anxiety w/ Dr and other medical
providers

Medical complications frequently
interrupt rehab participation
 One study (Siegler et al 1994) found that, of 1075
patients admitted to rehab, 359 (33.4%) had acute
medical complications on rehabilitation considered
severe enough to interrupt treatment.
 Of the 359 patients, 158 (44%) required an unexpected
transfer off rehabilitation.
 This may include critical care …

 Further analyses revealed major risk factors for
complications leading to transfer off-unit:
 a primary diagnosis of deconditioning or nontraumatic
spinal cord injury
 severity of initial disability
 number of comorbid conditions
(Siegler, Stineman & Maison, 1994)
Sounds like a lot of our patients …
Nevertheless, we know that pts w/ medical
comorbidities can make reasonable gains during
rehab …

For example, in a retrospective database
review of 175 rehabilitation patients with
comorbidities,
 Lee, Lee, Date, Zeiner (2002) concluded:
 “Except for life-threatening medical emergencies,
patients may benefit by staying on the acute rehab
unit, where both medical management and a
comprehensive rehabilitation program are provided
with continuity.”

Given the medical complexity
of our patients…
 What are some things to keep in mind that may
present barriers to optimum participation and
benefit from rehabilitation?
 How can we avoid the Fundamental Attribution
Error in our work with patients?

Given the medical complexity
of our patients…
 Bottom line: If we ascribe behavior solely to
psychological/motivational factors, this can lead to
over-treatment with psychotropics,
 while underestimating the impact of medical
complications & current environmental factors.

 Because rehabilitation is so demanding of
patient’s behavioral capacities, and because it all
takes place under close observation over an
extended period of time…
 The rehabilitation unit is a goldmine of
behavioral data to inform us:
 not only about the person’s progress
 but about the great sensitivity of the human organism
to changes in lab values or medication regimens that
may not usually be considered as having a clinical
impact.

You know this already, but it’s often
overlooked or under-rated…
 We’ll see in the clinical example later:
 ++++++++++++++++++++++++++++++++++++
 Behavior (and changes in behavior) can be a highly
sensitive indicator, even a prodrome, for medical
complications AND for response to medical interventions.
++++++++++++++++++++++++++++++++++++++++++

Rehabilitation places large demands on
higher level cognition and coping:
 A switch from passive mode to active mode
 Learning the names and roles of a large team
 Learning how to do activities in a different way
 Learning equipment. Learning routes in the hosp.
 Being around a lot of people (this may be a big change for
some)
 Being watched and evaluated
 Waiting, and being on the unit’s schedule
 Functioning adequately while SLEEP DEPRIVED!

A sample of co-morbidities with greater
impact on behavior than you might suppose:
 Anemia
 Hypo and hyperglycemia
 Hypo and hyperthyroid
 UTIs
 COPD
 Hyponatremia
 Sleep apnea
 and the ubiquitous sleep deprivation
 plus medication side effects …

Note: the issue is not just delirium…
 Side effects and co-morbidities that are far short of
causing frank delirium can significantly interfere with
higher level psychological and neuropsychological
functions that are required for a good response to
rehabilitation.
 Plus, could it be that non-severe comorbidities and mild
side effects have cumulative, unexpected impact on
higher functions?

Anemia
 The hypoxic condition caused by even mild anemia
can negatively affect physical function, cognitive
performance, mood, and quality of life,
 as found in a large community sample of individuals aged
65–84 years, comparing persons with mild anemia and a
randomly selected sample of non-anemic controls
 Mild anemia was defined as a hemoglobin
concentration between 10.0 and 11.9 g/dL in
women and between 10.0 and 12.9 g/dL in men.
Lucca, Ugo, et al. (2008)

Hypo and hyperglycemia
 Hypoglycemia’s impact on cognition is well-
recognized.
 But also can cause or exacerbate depressed mood and
feelings of anxiety and panic
 Less well-known are the effects of
hyperglycemia, often experienced acutely by our
pts even without h/o diabetes, e.g.
 Sommerfield, Deary and Friar (2004):
During acute hyperglycemia, cognitive function was
impaired and mood state deteriorated in a group of
people with type 2 diabetes.

Prior experience of delirium
 Patients coming from critical care units may be
especially likely to have undergone some episode of
delirium.
 Jones et al (2001) found that for some, delusional
memories persisted and this predicted longer-term,
clinically significant anxiety.
 Patients who have experienced delirium are more
likely to show some degree of long-term cognitive
deficit relative to pre-delirium baseline

ARDS: A common pre-rehab admission
experience (MANY of our pts)
 Hopkins, et al. (2005): Their study, following 74
ADRS pts (w/ no prior neurological disease) for 2
years, found cognitive deficits at hospital DC, 1 yr
and 2 yr follow-ups.
 ARDS resulted in significant neurocognitive and
emotional morbidity and decreased quality of life
that persisted at least 2 years after hospital
discharge.

They concluded:
 The cognitive impairments in the patients with ARDS
appear to be under-recognized by ICU and
rehabilitation providers.
 Education regarding cognitive sequelae after ARDS is
needed to enhance referral of patients to
rehabilitation, not only for physical debilitation and
weakness, but also for cognitive impairments.

 Hyponatremia is fairly common in hospitalized patients,
especially elderly.
 Different published articles describe different levels of
hyponatremia associated with symptoms. There can be
subtle effects at mild levels of derangement.
 Symptoms can be more notable when drop in sodium is
rapid versus slow.
 In rehab setting we may get a clearer picture of subtle
symptoms because of close observation in a demanding
environment.

Neurological signs
 At different severity levels, there may be:
 Mild (125 and 130 mmol/l)
○ anorexia, headache, nausea, vomiting, lethargy.
 Moderate (115 and 125 mmol/l)
○ personality change, muscle cramps and weakness,
confusion, ataxia.
 Severe (<115 mmol/l )
○ drowsiness; seizures, coma

When the cause is SIADH
(as was concluded for our Case Example)
 SIADH is a clinical manifestation of a wide range of
clinical disorders and drug therapies.
 Etiology may be medications:
 Various literature has pointed to a wide variety of
medications, including but not limited to antidepressants,
antiseizure medications, quinolones, haloperidol and many
others, as well as combinations
 (SIADH is also commonly associated with intracranial
diseases, particularly traumatic brain injury)

Our patient, Mr. C
 “An 80+-year-old man with a history of:
 coronary artery disease,
 chronic systolic heart failure,
 type 2 diabetes mellitus,
 stage III chronic kidney disease,
 hypertension,
 hyperlipidemia,
 GERD, possible esophageal dysmotility,
 depression, and
 recent posterior spinal fusion for cervical stenosis.”

 He was admitted to Acute Rehab in
February from the Neurosurg unit,
where his sodium level had fluctuated.
 It continued downward after his admit
to our unit.
 Various measures were taken to correct
it, and ultimately these were successful.

115
120
125
130
135
140
145
115
120
125
130
135
140
145
2-Feb 9-Feb 16-Feb 23-Feb 2-Mar 9-Mar 16-Mar 23-Mar 30-Mar 6-Apr 13-Apr
SodiumLabValues
Trend in Sodium Lab Values
Na

As his sodium went down…
 He appeared more lethargic, depressed and
anxious.
 His minutes of therapy dropped to zero.
 Psychotropic remedies were attempted, to no
avail, along with ongoing efforts to address his
hyponatremia.
 He developed swallowing problems as sodium
dropped further, and became disoriented.
 Discharge to SAR was planned.

0
60
120
180
240
300
360
420
480
115
120
125
130
135
140
145
TherapyMinutes
SodiumLabValues
Calendar Days (Sundays numbered)
Therapy Time and Sodium Lab Values Trending Together
Na total time

“Tell them I’m not usually like
this.
I want to get up. I want to get
better.
I’m not lazy. I don’t feel right.”
I just can’t do it.”

 Once the etiology of Mr. C’s hyponatremia was
determined to be SIADH, he was put on strict fluid
restriction plus salt tablets.
 Held: diazepam (3/7), and furosemide (3/2 ).
 DC’d: citalopram & tamsulosin (3/12).

0.1
1
10
100
1000
0
20
40
60
80
100
120
140
160
180
200
220
Citalo Diaza Trazo Loraz

10
100
1000
10000
100000
1000000
10
100
1000
10000
100000
1000000
Naprox Cipro Furosemide NaCl
Fluid
restriction
removed
Fluids
restricted to
500cc
Fluids
restricted to
1000cc

 Sodium levels rose steadily, and held WNL. Mood,
alertness, and minutes of therapy rose as well. Even
swallowing improved to “within functional limits”.
 Mood, alertness, minutes of therapy and swallowing
maintained even as fluid restriction was lifted and
furosemide was re-started.
 Conclusion was: “SIADH 2/2 medications; likely
citalopram, tamsulosin”
 He discharged to home with his daughter.

Importance of tracking info related
to risk of future delirium
 If we have observed acute changes in mental
status, this charted information should carry
forward for future reference in the pt’s subsequent
medical records.
 For whatever reason that it occurred, it represents
a greater risk for future delirium, which perhaps
could be forestalled with closer monitoring of
prodromal symptoms.

Questions? Other examples?
 Thanks, and you can contact me at
nmerbitz@med.umich.edu

Bibliography (not all were cited)
 Anderson RJ, Chung HM, Kluge R & Schrier RW. Hyponatremia: a prospective analysis of its
epidemiology and the pathogenetic role of vasopressin. Annals of Internal Medicine 1985 102
164–168.
 Cox, Daniel J., et al. "Relationships between hyperglycemia and cognitive performance among
adults with type 1 and type 2 diabetes." Diabetes Care 28.1 (2005): 71-77.
 Davydow, Dimitry S., et al. "Psychiatric morbidity in survivors of the acute respiratory distress
syndrome: a systematic review." Psychosomatic medicine 70.4 (2008): 512-519.
 De Miranda S, Pochard F, Chaize M, et al: Postintensive care unit psychological burden in patients
with chronic obstructive pulmonary disease and informal caregivers: A multicenter study. Crit
Care Med 2011; 39:112-118.
 Duppils, G. S. and Wikblad, K. (2004), Delirium: behavioural changes before and during the
prodromal phase. Journal of Clinical Nursing13: 609–616. doi: 10.1111/j.1365-2702.2004.00898.
 Gankam Kengne F, Andres C, Sattar L, Melot C & Decaux G. Mild hyponatremia and risk of
fracture in the ambulatory elderly. Quarterly Journal of Medicine 2008 101 583–588.

 Gonder-Frederick, Linda A., et al. "Cognitive Function Is Disrupted by Both Hypo-and
Hyperglycemia in School-AgedChildren With Type 1 Diabetes: A Field Study." Diabetes Care
32.6 (2009): 1001-1006.
 Hopkins, R, Jackson et al. Two-year cognitive, emotional, and quality-of-life outcomes in
acute respiratory distress syndrome. American journal of respiratory and critical care
medicine 171.4 (2005): 340-347.
 Inouye SK, Bogardus ST Jr, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, Cooney
Jr LM. A multicomponent intervention to prevent delirium in hospitalized older patients. N
Engl J Med 1999; 340: 669–76
 Iwashyna TJ, Ely EW, Smith DM, Langa KM. Long-term Cognitive Impairment and Functional
Disability Among Survivors of Severe Sepsis. JAMA 2010; 304(16): 1787-1794.
 Jackson JC, Hart RP, Gordon SM, Shintani A, Truman B, May L, Ely EW. Six-month
neuropsychological outcome of medical intensive care unit patients. Crit Care Med
2003;31:1226–1234.
 Jones C, Griffiths RD, Humphris G, Skirrow PM. Memory, delusions, and development of
acute posttraumatic stress disorder-related symptoms after intensive care. Crit Care Med.
2001 Mar;29(3):573-80.

 Lew HL, Lee E, Date ES, Zeiner H: Influence of medical comorbidities and complications on
FIM™ change and length of stay during inpatient rehabilitation. Am J Phys Med Rehabil
2002;81:830–837.
 Lucca, Ugo, et al. "Association of mild anemia with cognitive, functional, mood and
quality of life outcomes in the elderly: the “Health and Anemia” study." PLoS One 3.4
(2008): e1920.
 Lundstrom M, Edlund A, Lundstrom G, Gustafson Y. Reorganization of nursing and medical
care to reduce the incidence of postoperative delirium and improve rehabilitation
outcome in elderly patients treated for femoral neck fractures. Scand J Caring Sci 1999;
13: 193–200.
 Marcantonio ER, Flacker JM, Wright RJ, Resnick NM. Reducing delirium after hip fracture:
a randomized trial. J Am Geriatr Soc 2001; 49: 516–22.
 McNicoll, L., Pisani, M.A., Ely, E.W., Gifford, D., & Inouye, S. K. (2005). Detection of
delirium in the intensive care unit: Comparison of confusion assessment method for the
intensive care unit with confusion assessment method ratings. Journal of the American
Geriatrics Society, 53, 495–500.
 Olofsson B, Lundström M, Borssén B, Nyberg L, Gustafson Y. Delirium is associated with
poor rehabilitation outcome in elderly patients treated for femoral neck fractures.
Scandinavian Journal Of Caring Sciences [serial online]. June 2005;19(2):119-127.

 Pandharipande, P. P., et al. "Long-term cognitive impairment after critical illness." New
England Journal of Medicine 369.14 (2013): 1306-1316.
 Renneboog B, Musch W, Vandemergel X, Manto MU & Decaux G. Mild chronic
hyponatremia is associated with falls, unsteadiness, and attention deficits. American
Journal of Medicine 2006 119 71e1–71e8.
 Robinson, T. N., & Eiseman, B. (2008). Postoperative delirium in elderly: Diagnosis and
management. Clinical nterventions in Aging, 3, 351–355.
 Siegler, Eugenia L., Margaret G. Stineman, and Greg Maislin. "Development of
complications during rehabilitation." Archives of internal medicine 154.19 (1994): 2185.
 Thomas, R. I., Cameron, D. J., & Fahs, M. C. (1988). A prospective study of delirium and
prolonged hospital stay: Exploratory study. Archives of General Psychiatry, 45, 937–940.
 Torpy, J. M., Burke, A. E., & Glass, R. M. (2008). Delirium. Journal of the American
Medical Association, 300(4), 2936.
 Truman, B., & Ely, E. W. (2003). Monitoring delirium in critically ill patients. Using the
confusion assessment method for the intensive care unit. Critical Care Nurse, 23, 25–
38.
 Woo MH, Smythe MA. Association of SIADH with selective serotonin reuptake
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