Objective：We analyzed whether activities of daily living (ADL) had an additive effect on the discharge destination of hospitalized older patients with internal medicine.

Methods：Of the 691 patients hospitalized for medical illness aged 65 years or older who received physical therapy during this study period, 186 patients were included in the analysis. The main outcome was the discharge destination. Participants were categorized in the home discharge group and other institution group. The Barthel Index (BI) was used to assess the ADL at the first physical therapy session. Multivariate logistic regression analysis was used to estimate the influence of the BI on determining the discharge destination. The cut-off point of the BI score was evaluated using a receiver operating characteristic curve.

Results：During the follow-up period, 17 participants (9.1%) could not be discharged to their homes. Logistic regression analysis showed that the BI influenced discharge destinations (odds ratio：1.54；95% confidence intervals：1.23-1.89). The cut-off point of the BI score for determining home discharge was 72.5 (sensitivity, 0.80；specificity, 0.94；area under the curve, 0.94；positive predictive value：0.99, negative predictive value：0.32).

Conclusions：These findings suggest that the BI is a useful predictor for determining the potential destination of hospitalized older patients following discharge. However, the results of this study have limitations such as a low negative predictive value and a limited number of subjects.

The patient was a 76-year-old woman who developed involuntary movements in both hands and gait disorder. Weakness in both lower limbs gradually worsened, and she was referred to our hospital. Neurological findings included spastic paraplegia, deep sensory disturbance, sensory ataxia, and bladder and bowel dysfunction. Approximately 4 months after the onset, she became unable to walk independently and had to use a walker. MRI showed a long spinal cord lesion extending from the cervical to thoracic spinal cord. Blood and spinal fluid samples tested positive for anti-human T-cell leukemia virus type 1 (HTLV-1) antibodies. Given these findings and subacute course, she was diagnosed with rapidly progressive HTLV-1 associated myelopathy (HAM). High levels of neopterin and CXCL10 in the cerebrospinal fluid suggested high disease activity；thus, she underwent steroid pulse therapy followed by treatment with maintenance oral prednisolone in our convalescent rehabilitation ward. After approximately 3 months of muscle strength training, mainly for the trunk muscle and the proximal muscle of the lower limbs, and balance exercise, she was able to walk independently and her activities of daily living (ADL) and instrumental ADL (IADL) improved；however, dysuria persisted. The use of clean intermittent self-catheterization instead of indwelling urethral catheter improved her quality of life (QOL). Although rapidly progressive HAM is generally associated with poor prognosis, steroid therapy combined with comprehensive rehabilitation treatment was effective in the present case.

Hyperacute treatment after onset of cerebral infarction includes tissue plasminogen activator (t-PA) therapy for thrombolysis and endovascular treatment (EVT) with thrombectomy devices. Although reported infrequently, it has been noted that delayed white matter lesions may appear even when recanalization is obtained for occluded blood vessels. We report the rehabilitation progress of a patient treated with t-PA therapy and EVT for right internal carotid artery (ICA) occlusion in whom a delayed white matter lesion appeared in the subacute phase. In this case, EVT was performed after cerebral infarction, and the occluded blood vessel was completely reopened. After hyperacute treatment, mild motor paralysis was observed and basic movements were all assisted, but physical functions and movement abilities improved with continued treatment and rehabilitation. However, consciousness disorder and higher brain dysfunction appeared in the subacute phase, and motor paralysis progressed. This change in symptoms were thought to be due to a delayed white matter lesion that appeared after EVT for cerebral infarction. Physical functions were aggravated, but symptoms improved biphasically. There remain many unclear points about delayed white matter lesions, and there are various reports as to whether or not worsening symptoms eventually improve. Even if imaging shows that a delayed white matter lesion persists, as in this case, symptoms may again recover. Therefore it is necessary to be careful with rehabilitation.