Unsteadiness reported by older hospitalized patients predicts functional decline

Functional trajectories associated with acute illness and hospitalization in oldest old patients: Impact on mortality

Background: The literature pays low attention to functional changes during acute illness in older patients. Our main objectives were to separately describe the different functional changes occurring before and after hospital admission in oldest old medical patients, to investigate their association with mortality, and identify predictors associated with in-hospital failure to recover function.

Methods: Secondary analysis of data from a prospective cohort study conducted in a tertiary teaching hospital. The study followed the STROBE criteria. The sample included 604 consecutive patients aged 65 or older hospitalized for acute illness, discharged alive, and not fully dependent at baseline. Activities of daily living measured at baseline, admission, and discharge were used to classify patients into four functional trajectories depending on whether they decline or remain stable between baseline and admission (prehospital) and whether they decline, remain stable, or recover baseline function between admission and discharge (in-hospital). Multivariate models were used to test the association between functional trajectories with mortality, and predictors for in-hospital recovery.

Results: Functional trajectories were: “stable-stable” (18%); “decline-recovery” (18%); “decline-no recovery” (53%); “in-hospital decline” (11%). Prehospital decline occurred in 75% and 64% were discharged with worse function than baseline. “In-hospital decline” and “decline-no recovery” trajectories were independently associated with higher 6- and 12-month mortality. Extent of prehospital decline and dementia were predictors of failure to in-hospital recovery.

Conclusion: In acutely ill older people, differentiating between prehospital and in-hospital functional changes has prognostic implications. Lack of functional regain at discharge is associated with higher mortality at 6- and 12-months.

Transmetatarsal and Minor Amputation Versus Major Leg Amputation: 30-Day Readmissions, Reamputations, and Complications

AIMS

The optimal level of lower-extremity amputation, particularly in diabetic patients with ulceration, is debated. Proximal amputations more greatly decrease function versus distal amputations, but healing and complication rates may differ between the 2 types. This study compares early postoperative outcomes after transmetatarsal and other partial foot amputations and major leg amputations.

METHODS

Data were derived from National Surgical Quality Improvement Program datasets covering 2012 to 2014. Outcomes studied include 30-day rates of readmission to hospital for wound complications. We matched the 2 types of amputation patients by propensity score to fairly compare between levels of amputation when either type of amputation might be indicated. The same analysis was then performed with emphasis on diabetic patients.

RESULTS

Major amputation patients were more likely to have dependent functional status, although their surgeries tended to be more complicated. Minor amputation patients had 2.5 times the odds of irrigation and debridement compared with major amputation patients, but only 0.49 and 0.47 times the odds of urinary tract infection or transfusion, respectively.

CONCLUSIONS

Although short-term complications, readmissions, and reoperations were more common in distal amputation, UTI and the need for transfusion were higher in major amputation.

Changes in physical activity predict changes in a comprehensive model of balance in older community-dwelling adults. A longitudinal analysis of the TILDA study

Objective:

Falls due to poor balance can cause injury, disability, and death in older adults. The relationship between free-living physical activity (PA) and balance over time is poorly understood. The aim of this study is to explore the association between PA and balance in older adults over time

Methods:

Using two waves of data from the TILDA study (n=8,504 participants) a structural equation model was used to identify a composite measure of balance that incorporated measures of Timed Up and Go; handgrip strength; Mini Mental State Exam; vision; hearing; and steadiness. The patterns of change in PA and balance were then compared over time (controlling for covariates)

Results:

The results showed that one extra metabolic equivalent of task (MET) minute of PA improves balance by 4% over one week (Est=-0.10, SE=0.12), and by 5% cumulatively over two years (Est=-0.13, SE=0.02). Medication, alcohol consumption, sex, age, fear of falling, education, pain, and problems performing activities of daily living (ADL) were risk factors for balance

Conclusion:

This study provides a novel and robust model that should guide comprehensive balance assessment. PA promotion should engage older adults in more free-living PA that may be more relevant to them.

Functional trajectories of older acute medical inpatients

OBJECTIVES

To describe the changes in basic activities of daily living (BADL) function before and during hospital admission in older patients admitted to an acute medical unit and to assess the effect of age on loss of BADL function.

METHODS

Prospective observational study. The study included 91 patients aged 65 and older consecutively admitted to an acute medical unit of an urban public teaching hospital in Portugal, between May and September 2017. Functional status was measured at three times: at hospital admission; at about 2 weeks before hospital admission (baseline); an on the discharge day. The functional condition was evaluated using the Katz index. Differences in scores for BADL between baseline and admission, between admission and discharge, and between baseline and discharge were used to define pre-admission, in-hospital and overall functional decline.

RESULTS

Pre-admission, in-hospital and overall functional decline occurred in 78.0%, 4.4% and 63.7% of the participants, respectively. In contrast, in-hospital functional improvement occurred in a minority of the patients (14.3%). Hospitalized older people are discharged with BADL function that is worse than their baseline function. The oldest patients are at high risk of poorer functional outcomes because they are less likely to recover BADL function lost before admission.

CONCLUSION

These results emphasize the overriding need for implementing in-hospital processes to prevent functional decline and enhance functional recovery. This study also highlights the need for nurses to closely monitor the functional status of hospitalized older people, particularly in oldest-old patients.

The Acute Care for Elders Unit Model of Care

Older patients are at risk for loss of self-care abilities during the course of an acute medical illness that results in hospitalization. The Acute Care for Elders (ACE) Unit is a continuous quality improvement model of care designed to prevent the patient's loss of independence from admission to discharge in the performance of activities of daily living (hospital-associated disability). The ACE unit intervention includes principles of a prepared environment that encourages safe patient self-care, a set of clinical guidelines for bedside care by nurses and other health professionals to prevent patient disability and restore self-care lost by the acute illness, and planning for transitions of care and medical care. By applying a structured process, an interdisciplinary team completes a geriatric assessment, follows clinical guidelines, and initiates plans for care transitions in concert with the patient and family. Three randomized clinical trials and systematic reviews of ACE or related interventions demonstrate reduced functional disability among patients, reduced risk of nursing home admission, and lower costs of hospitalization. ACE principles could improve elderly care in any acute setting. The aim of this commentary is to describe the ACE model and the basis of its effectiveness.

How do muscle and bone strengthening and balance activities (MBSBA) vary across the life course, and are there particular ages where MBSBA are most important?

This narrative review focuses on the role of strength and balance activities throughout the lifecycle to improve physical capacity and reduce all-cause mortality. The evidence suggests strong associations in middle and older age, with poor balance, poor strength or poor physical function having strong associations with mortality. Currently in the UK, the proportions of adults (69% of men and 76% of women) not meeting the strength and balance guidelines (of 2 or more sessions/week) is concerning. This report identifies specific time points in the lifecycle where specific promotion of and engagement with strength and balance activities would be most beneficial for health: 18-24y to maximize bone and muscle mass gains, 40-50y to maintain strength and reduce that downward cycle, and over 65s to preserve balance and strength and maintain independence). This review also suggests specific transition points/events in life where there may be an increase in sedentary behaviour or loss of muscle function (pregnancy, menopause, onset of on diagnosis of disease, retirement, on becoming a carer and following hospitalization), where it would be useful to initiate additional strength and balance exercises to improve future health outcomes.

Which strength and balance activities are safe and efficacious for individuals with specific challenges (osteoporosis, vertebral fractures, frailty, dementia)?: A Narrative review

Physical activity guidelines advocate the inclusion of strength and balance activities, twice a week, for adults and older adults, but with caveat that in some individuals there will be certain movements and activities that could lead to adverse events. This scoping review summarizes the evidence about how safe and efficacious these activities are in older adults with specific challenges that might make them more prone to injury (e.g. having recently fractured or at risk of fracture (osteoporosis) or those who are frail or who have cognitive impairment). The review identified that for prevention of falls in people with a falls history and/or frailer older adults, structured exercise programmes that incorporate progressive resistance training (PRT) with increasing balance challenges over time are safe and effective if performed regularly, with supervision and support, over at least 6 months. Some minor adverse effects mainly transient musculoskeletal pain) have been reported. For those with a higher risk of falls and fractures (very poor balance, vertebral fractures), supervised structured exercise programmes are most appropriate. People with diagnosed osteoporosis should be as active as possible and only avoid activities with a high risk of falls if they are naïve to those activities. For those in transition to frailty who have poor strength and balance, exercises that are known to help maintain strength and balance (such as Tai Chi) are effective in preventing a decline in falls risk. For the very frail older adult, supervised structured exercise that has PRT, balance training and some endurance work, supervised and progressed by a trained person are advocated.

Functional trajectories of older patients admitted to an Acute Care Unit for Elders

AIMS AND OBJECTIVES

To describe the functional trajectories of older medical inpatients and to identify factors associated with overall and in-hospital functional decline.

BACKGROUND

Functional decline during a hospital stay is an important clinical outcome because independence remains a major determinant of older persons' quality of life and health care demands.

DESIGN AND METHODS

Participants (n = 189) were admitted to the Acute Care Unit for Elders of a Swiss academic hospital and were aged 65 years and older. Performance in basic activities of daily living at home (self-reported), at hospital admission (observed) and at discharge (observed) was collected. Differences in scores for basic activities daily living between baseline and admission, between admission and discharge, and between baseline and discharge were used to define pre-admission, in-hospital and overall functional decline. Predictors of in-hospital and overall decline were identified using bivariate and multivariate logistic regression analyses.

RESULTS

Pre-admission, in-hospital and overall functional decline occurred in 56.1%, 17.5% and 43.4% of the participants, respectively. In contrast, in-hospital functional improvement occurred in 40.2% of the participants. No predictors of pre-admission decline were identified, whereas pre-admission performance in instrumental activities of daily living was associated with in-hospital decline. Male gender and in-hospital delirium were associated with overall functional decline.

CONCLUSIONS

Most older inpatients experienced functional decline before their hospital admission, but only a minority experienced decline during their stay. Importantly, delirium was a strong predictor of overall functional decline.

IMPLICATIONS FOR PRACTICE

Low performance in instrumental activities of daily living prior to admission and delirium occurrence identified older patients at higher risk for in-hospital and overall functional decline. Gerontological nurses should play a key role in identifying these patients to provide preventative interventions and recovery care to preserve or restore their functional independence.

Recognition and management of psychosocial issues in diabetic neuropathy

Although psychosocial aspects of diabetic neuropathy (DN) have received far less attention than biological aspects, research conducted over the last decade has begun to illuminate several important pathways between DN and psychosocial outcomes, including depression, anxiety, and self-management of diabetic foot ulcer (DFU)-risk. Growing body of evidence indicates that DN is a risk factor for depression predicting both the severity and increments in depression over time. Whereas painful DN contributes to depression, postural instability is the DN symptom with the strongest, cumulative effect on depression. Furthermore, depression and foot self-care, while having no impact on the development of recurrent diabetic foot ulcers (DFU), play a substantial role in incident first DFU. Patient common sense misconceptions about DFU risks and associated emotional responses play an important role in shaping foot self-care. Depression, and especially DFU-specific emotions, may be linked to DFU chronicity through biological and behavioral pathways that are at present under investigation in several ongoing trials. Integrative approaches that target psychological factors such as anxiety and depression while concurrently optimizing treatment and self-management may therefore be most powerful. Cognitive behavioral therapy-based techniques that are informed by these findings deserve investigation.

Functional independence of long-living elderly at hospital admission

The aim of this quantitative cross-sectional study was to assess the functional independence of long-living elderly at the time of hospitalization. The study was conducted in two teaching hospitals, in the period between January and June of 2011, with 116 long-living elderly. The Functional Independence Measure Scale was applied for data collection and data analyses were performed using descriptive statistics. The score of the total Functional Independence Measure varied from 48 to 126, with a mean of 105.9% (±17.9), which represents functional independence. The motor Functional Independence Measurement of 30 to 91 (77.3%; ±14.5) and the social/cognitive Functional Independence Measurement of 18 to 35 (28.6%; ±4.9). At the hospital admission, the long-living elderly appeared to be independent in all of the Functional Independence Measurement domains. Knowing the functional capacity is essential to plan care throughout the entire hospitalization process.

Conducting high-value secondary dataset analysis: an introductory guide and resources

Secondary analyses of large datasets provide a mechanism for researchers to address high impact questions that would otherwise be prohibitively expensive and time-consuming to study. This paper presents a guide to assist investigators interested in conducting secondary data analysis, including advice on the process of successful secondary data analysis as well as a brief summary of high-value datasets and online resources for researchers, including the SGIM dataset compendium ( www.sgim.org/go/datasets ). The same basic research principles that apply to primary data analysis apply to secondary data analysis, including the development of a clear and clinically relevant research question, study sample, appropriate measures, and a thoughtful analytic approach. A real-world case description illustrates key steps: (1) define your research topic and question; (2) select a dataset; (3) get to know your dataset; and (4) structure your analysis and presentation of findings in a way that is clinically meaningful. Secondary dataset analysis is a well-established methodology. Secondary analysis is particularly valuable for junior investigators, who have limited time and resources to demonstrate expertise and productivity.

Reducing "iatrogenic disability" in the hospitalized frail elderly

BACKGROUND

Hospitalization is the first cause of functional decline in the elderly: 30 to 60% of elderly patients lose some independence in basic activities of daily living (ADL) during a stay in hospital. This loss of independence results from the acute condition that led to admission, but is also related to the mode of management.

OBJECTIVE

This paper is a review of the literature on functional decline in elderly hospitalized patients. It is the first stage in a project aiming to prevent dependence that is induced during the course of care.

METHODS

During a 2-day workshop in Monaco, a task force of 20 international experts discussed and defined the concept of "iatrogenic disability".

RESULTS

1- "Iatrogenic disability" was defined by the task force as the avoidable dependence which often occurs during the course of care. It involves three components that interact and have a cumulative effect: a) the patient's pre-existing frailty, b) the severity of the disorder that led to the patient's admission, and lastly c) the hospital structure and the process of care. 2- The prevention of "iatrogenic disability" involves successive stages. - becoming aware that hospitalization may induce dependence. Epidemiological studies have identified at-risk populations by the use of composite scores (HARP, ISAR, SHERPA, COMPRI, etc). - considering that functional decline is not a fatality. Quality references have already been defined. Interventions to prevent dependence in targeted populations have been set up: simple geriatric consultation teams, single-factor interventions (aimed for example at mobility, delirium, iatrogenic disorders) or multidomain interventions (such as GEM and ACE units, HELP, Fast Track, NICHE). These interventions are essentially centered on the patient's frailty and have limited results, as they take little account of the way the institution functions, which is not aimed at prevention of functional decline. The process of care reveals shortcomings: lack of geriatric knowledge, inadequate evaluation and management of functional status. The group suggests that interventions must not only identify at-risk patients so that they may benefit from specialized management, but they must also target the hospital structure and the process of care. This requires a graded "quality approach" and rethinking of the organization of the hospital around the elderly person.

A clinical index to stratify hospitalized older adults according to risk for new-onset disability

BACKGROUND

Many older adults who are independent prior to hospitalization develop a new disability by hospital discharge. Early risk stratification for new-onset disability may improve care. Thus, this study's objective was to develop and validate a clinical index to determine, at admission, risk for new-onset disability among older, hospitalized adults at discharge.

DESIGN

Data analyses derived from two prospective studies.

SETTING

Two teaching hospitals in Ohio.

PARTICIPANTS

Eight hundred eighty-five patients aged 70 years and older were discharged from a general medical service at a tertiary care hospital (mean age 78, 59% female) and 753 patients discharged from a separate community teaching hospital (mean age 79, 63% female). All participants reported being independent in five activities of daily living (ADLs: bathing, dressing, transferring, toileting, and eating) 2 weeks before admission.

MEASUREMENTS

New-onset disability, defined as a new need for personal assistance in one or more ADLs at discharge in participants who were independent 2 weeks before hospital admission.

RESULTS

Seven independent risk factors known on admission were identified and weighted using logistic regression: age (80-89, 1 point; ≥90, 2 points); dependence in three or more instrumental ADLs at baseline (2 points); impaired mobility at baseline (unable to run, 1 point; unable to climb stairs, 2 points); dependence in ADLs at admission (2-3 ADLs, 1 point; 4-5 ADLs, 3 points); acute stroke or metastatic cancer (2 points); severe cognitive impairment (1 point); and albumin less than 3.0 g/dL (2 points). New-onset disability occurred in 6%, 13%, 18%, 34%, 35%, 45%, 50%, and 87% of participants with 0, 1, 2, 3, 4, 5, 6, and 7 or more points, respectively, in the derivation cohort (area under the receiver operating characteristic curve (AUC)=0.784), and in 8%, 10%, 27%, 38%, 44%, 45%, 58%, and 83%, respectively, in the validation cohort (AUC=0.784). The risk score also predicted (P<.001) disability severity, nursing home placement, and long-term survival.

CONCLUSION

This clinical index determines risk for new-onset disability in hospitalized older adults and may inform clinical care.

Timing and risk factors for functional changes associated with medical hospitalization in older patients

BACKGROUND

Older medical patients often experience a decline in function associated with hospitalization. Some of this decline is already established at hospital admission, whereas some occurs during hospitalization. Objectives of this study were to separately describe pre-hospital and in-hospital functional changes in older Australian medical patients and to identify risk factors associated with these functional changes.

METHODS

Secondary analysis of data from a prospective controlled trial conducted in general medical units of an Australian tertiary teaching hospital. Participants were 615 consecutive patients aged 65 years or older admitted under a general medical unit for more than 2 days, discharged alive, and not fully dependent at pre-admission baseline. Activities of daily living measured 2 weeks before admission, at admission, and at discharge were used to calculate rates of pre-hospital and in-hospital decline and of in-hospital recovery to pre-admission function. Potential predictors including age, sex, diagnosis, illness severity, pre-admission function, pre-admission supports, and documented "geriatric syndromes" (dementia, falls, malnutrition) were investigated for each functional change outcome using multiple logistic regression models.

RESULTS

Sixty-four percent of participants had pre-hospital functional decline; only 42% of these had recovered to pre-admission function by hospital discharge. Only 7% had in-hospital decline. The different functional change variables had distinct patterns of predictors.

CONCLUSIONS

Most decline occurred prior to hospitalization and was associated with common indicators of poor outcomes in hospitalized elders. In-hospital decline was uncommon, suggesting that in-hospital recovery may be a more appropriate intervention target.

Fatores que predispõem ao declínio funcional em idosos hospitalizados

RESUMO INTRODUÇÃO: O aumento da expectativa de vida é uma realidade mundial e determina maior prevalência de doenças crônicas e maior demanda pelos serviços de saúde, incluindo os hospitalares. Atualmente, estudos têm focalizado o declínio funcional e suas consequências - demanda por recursos materiais e humanos, institucionalização e hospitalização. O objetivo foi a revisão crítica da literatura disponível sobre os fatores de risco associados ao declínio funcional em idosos hospitalizados. METODOLOGIA: Pesquisa nas bases de dados MEDLINE, LILACS e SCIELO, nos idiomas inglês e português, entre 2000 e 2007, utilizando as palavras-chave hospital, elderly, functional status, aged e functional decline e referências bibliográficas dos artigos selecionados. RESULTADOS: Satisfizeram os critérios de inclusão 31 publicações. Após leitura crítica do ABSTRACT, os 15 artigos mais relevantes foram selecionados. CONCLUSÃO: O declínio funcional pode ocorrer antes, durante e/ou após a hospitalização. Idade avançada, comprometimento funcional prévio, déficit cognitivo, iatrogenias, gravidade da condição clínica e histórico de quedas foram os fatores de risco mais citados. A capacidade funcional, como marcador de saúde desse grupo, merece maior investigação.

Predictors of depressive symptoms in persons with diabetic peripheral neuropathy: a longitudinal study

AIMS/HYPOTHESIS

The aim of the study was to determine whether diabetic peripheral neuropathy (DPN) is a risk factor for depressive symptoms and examine the potential mechanisms for this relationship.

METHODS

This longitudinal study (9 and 18 month follow-up) of 338 DPN patients (mean age 61 years; 71% male; 73% type 2 diabetes) examined the temporal relationships between DPN severity (mean +/- SD; neuropathy disability score [NDS], 7.4 +/- 2.2; mean vibration perception threshold, 41.5 +/- 9.5 V), DPN somatic experiences (symptoms and foot ulceration), DPN psychosocial consequences (restrictions in activities of daily living [ADL] and social self-perception) and the Hospital Anxiety and Depression subscale measuring depressive symptoms (HADS-D; mean 4.9 +/- 3.7).

RESULTS

Controlling for baseline HADS-D and demographic/disease variables, NDS at baseline significantly predicted increased HADS-D over 18 months. This association was mediated by baseline unsteadiness, which was significantly associated with increased HADS-D. Baseline ADL restrictions significantly predicted increased HADS-D and partly mediated the association between baseline unsteadiness and change in HADS-D. Increased pain, unsteadiness and ADL restrictions from baseline to 9 months each significantly predicted increased HADS-D over 18 months. Change in social self-perception from baseline to 9 months significantly predicted increased HADS-D and partly mediated the relationships of change in unsteadiness and ADL restrictions with change in HADS-D.

CONCLUSIONS/INTERPRETATION

These results confirm that neuropathy is a risk factor for depressive symptoms because it generates pain and unsteadiness. Unsteadiness is the symptom with the strongest association with depression, and is linked to depressive symptoms by perceptions of diminished self-worth as a result of inability to perform social roles.

[Influence of functional dependence on the case mix in a geriatric unit]

OBJECTIVE

To determine the influence of pre-admission functional status on the case mix in a geriatric unit, after adjustment by the diagnosis-related groups (DRG) patient classification system.

MATERIAL AND METHODS

We performed a retrospective observational study in patients admitted to the geriatric unit of a general hospital over a 2-year period. Patients with a length of stay of less than 2 days and transfers from other medical services and hospitals were excluded. The following data were obtained from the minimum data set and from chart review: age, sex, place of residence before admission, Charlson comorbidity index, pre-admission functional status and mobility, cognitive status, length of hospital stay, rate of in-hospital mortality, and the DRG (and DRG weight) for each patient.

RESULTS

A total of 1065 patients were included in this study. The mean age was 84 years (64-102), and 64% were women. Patients with lower functional status were more often female (67.1 vs 55.8%; P< .01), more frequently admitted from nursing homes (35.8 vs 14.7%; P< .01) and had higher mortality (19.3 vs 10.1%; P< .01). These patients also had a higher mean length of stay (12.7 vs 11.9), higher comorbidity scores (P< .01), greater cognitive impairment (P< .01) and higher DRG weight (P=.03). Once the more frequent DRG were reviewed, patients who were dependent had a greater number of respiratory infections and renal problems and had fewer cerebrovascular diseases.

CONCLUSIONS

Some clinical characteristics differ in patients with functional dependence. This finding could influence the clinical management of medical services that treat more dependent patients.

Characteristics of nondisabled older patients developing new disability associated with medical illnesses and hospitalization

OBJECTIVE

To identify demographic, clinical, and biological characteristics of older nondisabled patients who develop new disability in basic activities of daily living (BADL) during medical illnesses requiring hospitalization.

DESIGN

Longitudinal observational study.

SETTING

Geriatric and Internal Medicine acute care units.

PARTICIPANTS

Data are from 1,686 patients aged 65 and older who independent in BADL 2 weeks before hospital admission, enrolled in the 1998 survey of the Italian Group of Pharmacoepidemiology in the Elderly Study.

MEASUREMENTS

Study outcome was new BADL disability at time of hospital discharge. Sociodemographic, functional status, and clinical characteristics were collected at hospital admission; acute and chronic conditions were classified according to the International Classification of Disease, ninth revision; fasting blood samples were obtained and processed with standard methods.

RESULTS

At the time of hospital discharge 113 patients (6.7%) presented new BADL disability. Functional decline was strongly related to patients' age and preadmission instrumental activities of daily living status. In a multivariate analysis, older age, nursing home residency, low body mass index, elevated erythrocyte sedimentation rate, acute stroke, high level of comorbidity expressed as Cumulative Illness Rating Scale score, polypharmacotherapy, cognitive decline, and history of fall in the previous year were independent and significant predictors of BADL disability.

CONCLUSION

Several factors might contribute to loss of physical independence in hospitalized older persons. Preexisting conditions associated with the frailty syndrome, including physical and cognitive function, comorbidity, body composition, and inflammatory markers, characterize patients at high risk of functional decline.

Anemia and recovery from disability in activities of daily living in hospitalized older persons

OBJECTIVES

To evaluate the predictive value of hemoglobin levels upon hospital admission on recovery from activity of daily living (ADL) disability during hospital stay in older patients.

DESIGN

Longitudinal observational study.

SETTING

Geriatric and internal medicine acute care units.

PARTICIPANTS

Data are from 5,675 patients aged 65 and older enrolled in the Italian Group of Pharmacoepidemiology in the Elderly Study with ADL disability upon hospital admission.

MEASUREMENTS

ADL disability was defined as inability to perform or need for assistance in performing one or more ADLs. Recovery from ADL disability was defined as independence in ADLs upon hospital discharge. Anemia was defined according to the World Health Organization criteria. Sociodemographic and clinical characteristics were considered as potential confounders.

RESULTS

Mean age was 80.5 years; 57.7% of subjects were female. Prevalence of anemia was 46.8%. A total of 536 (9.4%) participants regained independence in all six ADLs at hospital discharge. Patients with anemia had a lower rate of recovery from ADL disability than those with normal hemoglobin levels (7.0% vs 11.6%; P<.001). Adjusted analyses confirmed that anemia was inversely associated with the likelihood of ADL recovery (odds ratio=0.71, 95% confidence interval=0.57-0.88). The probability of ADL recovery in anemic patients was higher at higher hemoglobin concentrations.

CONCLUSION

In older hospitalized patients, anemia is inversely associated with the likelihood of regaining ADL independence during a hospital stay.

Care of hospitalized older patients: opportunities for hospital-based physicians

BACKGROUND

Half of patients admitted to hospital for reasons unrelated to childbirth are age 65 years or older. Nonetheless, few hospital-based physicians have received training in geriatric medicine, and few geriatricians practice in the hospital. This paper describes the state of the science of hospital care for older patients, and identifies opportunities and barriers to improving their care.

METHODS

General medical journals from 1980 to the present were selectively reviewed to identify original articles on the treatment of specific diseases and syndromes on hospitalized persons age 65 years or older. Information was synthesized to describe the course of these patients during and after hospitalization, and to identify effective management strategies and gaps in knowledge.

RESULTS

Older persons in hospitals pose substantial clinical challenges: they have high rates of cognitive impairment, delirium, disability, and difficulty walking, and they often require increased attention, longer lengths of stay, and higher hospital costs than younger patients with the same diagnoses. Disease-specific interventions have not been studied extensively in those older than 75 years. Multicomponent interventions can reduce short-term rates of disability and delirium without increasing costs, but they have not been widely disseminated. Interventions to treat or prevent other common conditions in hospitalized older patients have not been proven effective.

CONCLUSIONS

Fundamental discoveries in the science of hospital medicine are needed to prevent or treat geriatric syndromes, to treat common diseases in the very old, and to put into practice what is known. Hospital-based physicians can address these gaps in knowledge and practice with geriatricians, building from their shared perspectives on the care of the aged in complex health systems.

Reliability and validity of a steadiness score

OBJECTIVES

To determine the internal consistency and construct and predictive validity of three survey questions regarding steadiness in a sample of community-dwelling lower-income older adults.

DESIGN

A 6-month prospective cohort study.

SETTING

Community-based.

PARTICIPANTS

Three hundred fifty-seven older adults who completed a baseline and 6-month follow-up interviewer-administered survey. These older adults received care at a single, public health system and were judged by insurance status to be of low income.

MEASUREMENTS

Self-report measures of steadiness while walking and transferring; difficulty in mobility, activities of daily living (ADLs), and instrumental activities of daily living (IADLs); chronic illness; falls; hospitalization; and sociodemographic characteristics.

RESULTS

The three steadiness questions showed good internal consistency (0.88); construct validity in Pearson correlations with mobility (0.57), ADL (0.53), and IADL scores (0.41); and predictive validity. With regard to predictive validity, steadiness was predictive of falls, hospitalization, and decline in ADL and IADL function over a subsequent 6-month period.

CONCLUSION

Steadiness questions are a potentially valuable addition to survey research and clinical screening to identify persons with current impairment status and falls and disability risk.