Variables asociadas a la recuperación funcional y la institucionalización al alta en ancianos ingresados en una unidad geriátrica de media estancia

Diagnostic accuracy study of the VALENF instrument in hospitalization units for adults: a study protocol

Recently, the VALENF instrument, Nursing Assessment by its acronym in Spanish, was developed as a meta-tool composed of only seven items with a more parsimonious approach for nursing assessment in adult hospitalization units. This meta-tool integrates the assessment of functional capacity, the risk of pressure injuries and the risk of falls. The general objective of this project is to validate the VALENF instrument by studying its diagnostic accuracy against the instruments commonly used in nursing to assess functional capacity, the risk of pressure injuries and the risk of falls. An observational, longitudinal, prospective study is presented, with recruitment and random selection based on admissions to six adult hospitalization units of the Hospital Universitario de La Plana. The study population will be made up of patients hospitalized in these units. The inclusion criteria will be patients over 18 years of age with a nursing assessment within the first 24 h of admission and an expected length of stay greater than 48 h and who sign the informed consent form. The exclusion criteria will be transfers from other units or centers. A sample of 521 participants is estimated as necessary. The evaluation test will be the VALENF instrument, and the reference tests will be the Barthel, Braden and Downton indices. Sociodemographic variables related to the care process and results such as functional loss, falls or pressure injuries will be collected. The evolution of functional capacity, the risk of falls and the risk of pressure injuries will be analyzed. The sensitivity, specificity and positive predictive values of the VALENF instrument will be calculated and compared to those of the usual instruments. A survival analysis will be performed for pressure injuries, falls and patients with functional loss. The VALENF instrument is expected to have at least the same diagnostic validity as the original instruments.Trial registration The study will be retrospectively registered (ISRCTN 17699562, 25/07/2023).

[Predictive ability of baseline frailty and handgrip strength at admission on outcomes at discharge in a geriatric functional recovery unit]

OBJECTIVE

To evaluate the predictive capacity of different frailty scales, as well as the strength of the handgrip, and to determine their relationship with clinical favourable outcomes.

PATIENTS AND METHOD

Prospective study of patients admitted to the Geriatric Functional Recovery Unit (GFRU) of the Hospital Central Cruz Roja. The «FRAIL» scale, «Clinical Frailty Scale» (CFS) and «Fragil-VIG» index, and handgrip strength by hydraulic dynamometer were completed on admission. A functional gain was assumed as 20 or more points in the Barthel Index and return to home, as good outcomes at discharge. The discriminative capacity of favourable outcomes for each frailty scale and handgrip strength was analysed by means of ROC curves, calculating the C statistic (area under the curve = AUC).

RESULTS

The analysis included 74 patients (median age 82 years; 48.5% women), admitted for stroke recovery (65%), orthopaedic pathology (16%), and other causes (19%). The prevalence of frailty varied between 31% (FRAIL scale), 40% (CFS), and 57.5% («Fragil-VIG»). Median handgrip strength was 15 Kg in males (interquartile range 11-21), and 9 Kg in females (interquartile range 7-12). At discharge, 51.5% of patients had a functional gain of 20 or more points in Barthel index, and 63% returned to their previous home. The discriminating ability to achieve acceptable functional gain at discharge was good for CFS (AUC = 0.72; 95% CI; 0.60-0.84) and «Fragil-VIG» (AUC = 0.72; 95% CI;0.58-0.82), and handgrip strength was the only tool related to return home (AUC = 0.68; 95% CI;0.56-0.81).

CONCLUSION

To evaluate frailty on admission to a GFRU contributes to predicting favourable clinical outcomes, but the discriminating capacity of each scale is variable.

[Impact of a centralised hospital admission system on the efficacy and efficiency of a geriatric functional recovery unit]

OBJECTIVE

To evaluate the influence of a change in the management of admissions on the activity and care outcomes of a Geriatric Functional Recovery Unit (GFRU).

MATERIAL AND METHODS

A retrospective observational study was conducted. Since 2000, the Hospital Central Cruz Roja GFRU has been collecting data grouped into periods of 4 years, except for the centralised admissions (September 2016-December 2018). The data collected on admission included the Red Cross Functional and Mental scales, the Barthel index, the main diagnosis of the functional decline (grouped into stroke, orthopaedic problem, and multifactorial immobility episodes), and comorbidity evaluated by the Charlson index. The following outcome variables were analysed: the overall and relative functional gain at discharge; length of hospital stay; the functional efficiency, discharges to nursing homes, and transfers to acute care units. An analysis was made of the relationship between the admissions from the centralised unit and the previous period (directly admission managed by GFRU), using multivariate analysis (linear regression for continuous outcome variables and logistic regression for the dichotomous ones), adjusted for admission variables.

RESULTS

Patients admitted from the centralised unit showed a greater overall and relative functional gain (difference between both means: 3.49 points, 95% CI; 1.65-5.33, and 12.41%, 95% CI; 0.74-24.08, respectively), longer stay (12.92 days, 95% CI; 11.54-14.30) and lower efficiency (-0.36, 95% CI; -0.16 to -0.57), higher risk of institutionalisation (OR 1.61, 95% CI; 1.19-2.16), and transfers to acute care units (OR 3.16, 95% CI; 2.24-4.47).

CONCLUSIONS

A centralised admissions system had an influence on the improvement of functional parameters in the patients, but with a longer length of hospital stay, and lower efficiency. Increases in institutionalisation at discharge and transfers to acute care units were also observed.

Relationship between hospitalization and functional and cognitive impairment in hospitalized older adults patients

OBJECTIVES

To study changes in the cognitive status and dependency of patients aged over 65 years during hospitalization for bone fracture and how these changes relate to the total number of days of admission and absolute rest during hospitalization. Along with cognitive decline, musculoskeletal disorders are considered key factors in this patient population. As well as requiring hospital admission and/or surgical treatment, fractures increase the risk factors that contribute to disability and dependency in older adults.

METHOD

A longitudinal case-series study with repeated follow-up assessments was conducted. The sample consisted of 259 older adults. The following tests were administered: Barthel index, Lawton-Brody's scale, Phototest, and informant questionnaire on cognitive decline in the elderly.

RESULTS

The main variable which fosters functional dependency, cognitive decline, and functional loss and diminishes functional gain (both in the hospital and at home) is the number of days of bed rest during hospitalization.

CONCLUSIONS

The present study reveals that the greater impact on levels of functional dependency and cognitive decline comes from the patient's days of bed rest in hospital, rather than the total days of hospitalization. These findings could be taken into consideration when discussing post-discharge functional recovery.

Functional status and mortality at month and year in nonagenarians hospitalized due to acute medical illness

OBJECTIVES

To analyze risk factors associated with short and long-term mortality in nonagenarians hospitalized due to acute medical conditions.

DESIGN, SETTING, AND PARTICIPANTS

Prospective study of all patients aged 90 years or older admitted in a geriatric unit during 2009 due to medical acute illness. Baseline variables were collected at admission (sex, cause of admission, Charlson index, serum albumin, functional, and mental status), functional loss at admission (as the difference between Barthel index(BI) 2 weeks before admission and BI at admission), and functional loss at discharge(as the difference between BI 2 weeks before admission and BI at discharge). The association of these variables with mortality at 1 month and 1 year after admission was analyzed by multivariate Cox regression analysis.

RESULTS

Out of all patients admitted, 434 (33%) were 90 years old or older and 76.3% were female. Mortality at 1 month and 1 year after admission was 19% and 57%, respectively. In the month mortality multivariate analysis, being older (HR, 1.11; 95% CI=1.02 to 1.20), a previous Barthel index less than 40 points (HR, 5.87; 95% CI=1.16 to 29.67), and functional loss at admission (HR; 1.13; 95% CI=1.03 to 1.25) were independent risk factors. When patients that died 1 month after admission were excluded, the presence of hypoalbuminemia <3g/dl (HR, 2.70; 95% CI=1.69 to 4.32) and functional loss at discharge (HR-1.08, 95% CI=1.03 to 1.14) were the factors associated with 1 year mortality.

CONCLUSIONS

In nonagenarians, functional impairment is the most important risk factor associated with short and long-term mortality after hospitalization due to acute medical illness.

Three measures of physical rehabilitation effectiveness in elderly patients: a prospective, longitudinal, comparative analysis

BACKGROUND

Rehabilitation success is measured by instruments that assess performance of activities of daily living. Guidelines on the use and choice of these instruments are lacking. The present study aimed to analyse prognostic indicators of physical rehabilitation effectiveness in elderly patients according to three rehabilitation impact indices.

METHODS

Prospective, longitudinal study in a post-acute care unit. The study included rehabilitation-eligible deconditioned elderly in-patients prospectively admitted to post-acute care (n = 685, aged 83.2 ± 8.3 years, mean length of stay 15 ± 9.2 days).

DATA COLLECTION

Premorbid health status variables (PHSV): age, sex, comorbidity (Charlson index), medical history (heart failure, pulmonary disease, cerebrovascular disease, dementia), previous living situation and pre-admission functional status (premorbid Lawton and Barthel indices). Admission health status variables (AHSV): main diagnoses, referral source, physical (Barthel-adm) and cognitive function (Pfeiffer test), undernutrition and dysphagia.

OUTCOME MEASURES

Absolute functional gain (AFG, admission-to-discharge Barthel change), relative functional gain (RFG, achieved percentage of potential gain) and rehabilitation efficiency index (REI, AFG over length of stay). Univariate analysis considered these parameters, along with PHSV and AHSV. Multivariate logistic regression analysis was performed for AFG ≥20, RFG ≥35 % and REI ≥ 0.50.

RESULTS

Greater AFG was associated with 14 variables, 8 PHSV (57.1 %) and 6 AHSV (42.8 %); greater RFG with 9 variables, 3 PHSV (33.3 %) and 6 AHSV (66.6 %); and REI with 9 variables, 4 PHSV (44.4 %) and 5 AHSV (55.5 %). Mean AFG value was 34.5 ± 15.8 in patients who achieved complete recovery (RFG 100 %, n = 189, 27.5 %) and 35.3 ± 15.0 (p = 0.593) in the remaining patients (n = 311, 45.4 %). In multivariate analysis, only Barthel-adm was related to all three rehabilitation impact indices.

CONCLUSIONS

Both premorbid and acute-process variables have a greater impact on AFG and REI, compared to RFG. Although AFG gives information about the degree of reduction in dependence, it does not provide clinical information about post-rehabilitation functional status (mean AFG values did not differ between patients with and without complete recovery). A future implication for evaluating rehabilitation effectiveness in elderly patients is to recommend RFG corrected by premorbid Barthel score, which is less affected by previous health conditions, as the optimum method to assess the degree to which maximum potential improvement was achieved.

Does gait speed contribute to sarcopenia case-finding in a postacute rehabilitation setting?

OBJECTIVE

The European Working Group of Sarcopenia in Older People (EWGSOP) has developed an algorithm based on gait speed measurement to begin sarcopenia case-finding in clinical practice, in which a cut-off point of <0.8m/s identifies risk for sarcopenia in community-dwelling older people. The objective of this study was to assess the application of the EWGSOP algorithm in hospitalised elderly patients with impaired functional capacity.

METHODS

One hundred in-patients (aged 84.1 SD 8.5, 62% women) were prospectively studied in a postacute care geriatric unit focused on rehabilitation. Sarcopenia was assessed by corporal composition (electrical bioimpedance), handgrip strength, and physical performance (gait speed). Other measurements were Charlson index, length of stay, and functional gain at discharge and 3-month follow-up. All patients were screened by the EWGSOP algorithm and sarcopenia was confirmed according to diagnostic criteria.

RESULTS

Gait speed was <0.8m/s in all cases and 58 patients had low muscle mass, which, according to the EWGSOP-algorithm, would indicate a diagnosis of sarcopenia. No differences were observed in functional capacity between these patients and those with normal muscle mass. When decreased handgrip strength was considered, 47 of these patients met the EWGSOP criteria for severe sarcopenia. In this group, differences in functional capacity were observed at discharge (Barthel 45.2 vs. 56.3, p=0.042) and 3-month follow-up (48.3 vs. 59.8, p=0.047).

CONCLUSION

The application of the EWGSOP algorithm in hospitalised, postacute, elderly patients with low gait speed suggested that muscle strength should be considered before confirming or discarding a sarcopenia diagnosis.

Sarcopenia, physical rehabilitation and functional outcomes of patients in a subacute geriatric care unit

Sarcopenia is the loss of muscle mass and strength, which in the elderly can result in disability and affect functional outcomes after hospitalization. The aim of this study was to evaluate the functional outcomes and mortality during hospitalization and at three months post-discharge, according to the presence of sarcopenia. Prospective study of 99 patients (38.4% men, aged 84.6) admitted in a subacute geriatric care unit who underwent a rehabilitation intervention. Main outcomes were mortality and functional improvement at discharge and at three-month follow-up. Sarcopenia was assessed by handgrip strength (hydraulic dynamometer) and by body composition bioimpedance. Forty-six (46.5%) patients met diagnostic criteria of sarcopenia. Patients with sarcopenia had a worse prior functional status than those without the condition (Barthel Index: 64.2±22.8 vs 73.3±21.8; p=0.04) but both groups had similar functional decline at admission (Barthel Index: 24±15.1 vs 28.5±15.2; p=0.1) and achieved similar functional improvement at discharge (20.4±18.3 vs 27.4±21; p=0.08). Barthel Index at discharge remained comparatively worse in patients with sarcopenia (44.2±26.6 vs 55.9±26.7; p=0.03). After completing a 3-month at-home rehabilitation program, no changes in functional capacity were observed in patients with sarcopenia; their peers improved their Barthel Index scores (45.5±24.8 vs 61.6±26.6; p=0.007). Mortality rates at 3-month follow-up did not differ between groups. In conclusion, patients with sarcopenia had a worse functional status, similar functional improvement during hospitalization and a lack of recovery after returning home. Further studies are needed to establish long-terms effects on mortality.

[Structured review of activities of daily living measures in older people]

OBJECTIVE

the present article evaluates the evidence relating to the conceptual adaptation, applicability and psychometric properties of activities of daily living measures in Spanish elderly people.

MATERIAL AND METHODS

to obtain original documents, electronic searches were carried out in Spanish (IME and ISOC) and international databases (MEDLINE, PsycInfo, CINAHL and EMBASE). Manual searches and reference searches were also conducted.

RESULTS

34 articles relating to 4 instruments met the inclusion criteria: the Barthel Index, the Katz Index, the Red Cross Scale of Physical Disability and the Subscale of Personal Care Activities from the OARS. Overall, the results show a large number of versions for each instrument with weak transcultural adaptation processes and without standards for their administration or interpretation. The most frequently evaluated reliability measure was interrater reproducibility. The evidence on predictive validity is extensive, but the evidence on concurrent validity and responsiveness is almost nil.

CONCLUSIONS

one version of the Barthel index and another one of the Katz index are the two versions about which the largest quantity of information has been obtained.