The Association Between Life-Space and Health Care Utilization in Older Adults with Heart Failure

Relationships between life-space mobility, physical function, and empowerment in patients with chronic obstructive pulmonary disease

[Purpose] This study aimed to elucidate the relationship between the Life-Space Assessment measure, which conceptualizes physical activity in terms of life-space, and indicators of empowerment, and physical function, in stable patients with chronic obstructive pulmonary disease. [Participants and Methods] This was a cross-sectional study. The participants were 25 stable outpatients with chronic obstructive pulmonary disease (22 males, mean age 75.6 ± 6.1 years). Measurements included the Life-Space Assessment; the Empowerment Scale for the Elderly; respiratory function; grip strength; weight-adjusted knee extension strength; and a six-minute walk test. Pearson's correlation coefficient and a multivariate analysis were used to examine the relationship between the Life-Space Assessment and each indicator, with the significance level set at 5%. [Results] The Life-Space Assessment score (83.4 ± 23.7 points) correlated with the percentage forced vital capacity and the six-minute walk distance. However, the Life-Space Assessment demonstrated no association with the Empowerment Scale for the Elderly (38.3 ± 7.0 points). [Conclusion]The results of this study suggest that physical function correlates with scores on the Life-Space Assessment in patients with stable chronic obstructive pulmonary disease.

Life-Space of Older Adults after Discharge from Skilled Nursing Facilities

OBJECTIVES

Describe (1) patient or caregiver perceptions of physical function in 30 days after skilled nursing facility (SNF) discharge indicated by Life-Space Assessment (LSA) scores, and (2) patient and caregiver factors associated with LSA scores.

DESIGN

Secondary analysis of baseline and outcomes data from the cluster randomized trial of the Connect-Home transitional care intervention.

SETTING AND PARTICIPANTS

Six SNFs in North Carolina. Patient and caregiver dyads with LSA scores (N = 245).

METHODS

SNF patients or their caregivers serving as proxy reported the life-space of the SNF patient using the LSA tool, a measure of environmental and social factors that influence physical mobility. Simple scores for highest life-space attained depending on equipment and/or caregiver support range from 0 to 5, with higher scores indicating greater mobility. Multiple linear regression models for simple LSA scores and Composite Life-Space (0-120), adjusted for treatment, time via a COVID pandemic indicator, and treatment × COVID effect as fixed effects, were used to estimate the association of patient and caregiver variables and life-space.

RESULTS

Patients had a mean age of 76.3 years, 62.6% were female, and 74.7% were white. Caregivers were commonly female (73.9%) and adult children of the patient (46.5%). The mean Composite Life-Space score was 22.6 (16.09). The mean Assisted Life-Space score (range: 0-5) was 1.6 (1.47), and 76.3% of patients could not move beyond their bedroom, house, and yard without assistance of another person. Higher Composite Life-Space scores were associated with lower levels of cognitive impairment and shorter SNF length of stay.

CONCLUSIONS AND IMPLICATIONS

SNF patients and their caregivers reported very low LSA scores in 30 days after SNF care. Findings indicate the need for care redesign to promote recovery of physical function of older adults after SNF discharge, such as optimizing SNF rehabilitative therapy and adding postdischarge rehabilitative supports at home.

Restricted life-space mobility impacts physical but not mental quality of life in older cancer survivors

BACKGROUND

Older cancer survivors often value quality of life (QOL) over survival. Life-space mobility (LSM), defined as the individual's spatial geographic mobility range, is an important QOL indicator in older adults with chronic illnesses; however, this relationship is unexplored in older cancer survivors.

METHODS

We examined the longitudinal associations and causal relationships between LSM and QOL in 153 older cancer survivors (≥65 years) from the University of Alabama at Birmingham (UAB) Study of Aging. LSM was assessed using the UAB Life-Space Assessment-Composite score (LSA-C), and QOL was assessed by the SF-12 Mental Component Score (MCS12) and Physical Component Score (PCS12) at 0 (study entry), 6, 18, 36, 54, and 72 months. We examined the causal relationship between LSM and QOL using a cross-lagged panel model (CLPM).

RESULTS

The cohort (n = 153) was 76 years old on average and predominantly White (58%), female (58%), and married (55%). Longitudinal analyses found LSM decreased over time (p < 0.0001), and this decrease was associated with decreased QOL (PCS12, p < 0.0001, MCS12, p < 0.0001). In the CLPM causal analysis, lower LSM resulted in worse PCS12 (p < 0.001), but not worse MSC12.

CONCLUSIONS

Restricted LSM resulted in worse physical QOL over 72 months in a sample of 153 older cancer survivors. Developing and evaluating interventions to preserve greater LSM could be a promising approach to improving QOL.

Life-space mobility and post-hospitalization outcomes among older Mexican American Medicare beneficiaries

BACKGROUND

Older adults with limited mobility are at an increased risk of adverse health outcomes, an outcome inadequately investigated in older Mexican Americans. We explored whether pre-admission life-space mobility predicts post-hospitalization outcomes among hospitalized Mexican American Medicare beneficiaries.

METHODS

Life-space mobility, using the Life-Space Assessment (LSA), was analyzed using quartiles and 5-point intervals. Using the Hispanic Established Populations for the Epidemiologic Study of the Elderly (HEPESE) Waves 7 and 8 data linked to Medicare claims data, 426 older Mexican Americans with at least 2 months of Medicare coverage who were hospitalized within 2 years of completing the LSA were included. Logistic and Cox Proportional regression analyses estimated the association of pre-admission LSA with post-hospitalization outcomes.

RESULTS

Prior to hospitalization, 85.4% reported limited life-space mobility. Most patients (n = 322, 75.6%) were hospitalized for medical reasons. About 65% were discharged to the community. Pre-admission LSA scores were not associated with community discharge (Odds Ratio [OR] = 1.02, 0.95-1.10). Higher pre-admission LSA scores were associated with 30-day readmission (OR = 1.11, 1.01-1.22). Patients in the highest pre-admission LSA quartile (i.e., greatest life-space mobility) were less likely to die within 2 years after hospital discharge (OR = 0.61, 0.39-0.97) compared to those with lower pre-admission LSA scores.

CONCLUSIONS

Among older Mexican American Medicare beneficiaries, greater pre-admission LSA scores were associated with an increased risk of 30-day readmission and a decreased risk of mortality within 2 years following hospitalization. Future work should further investigate the relationship between LSA and post-hospitalization outcomes in a larger sample of Mexican American older adults.

Life-Space Activities Are Associated with the Prognosis of Older Adults with Cardiovascular Disease

Life-space activities are a measure of daily activity level. Here, we examined the association between life-space activities and prognosis in 129 cardiovascular diseases (CVD) patients 65 years of age or older (average age, 79.2 ± 7.6 years; mean left ventricular ejection fraction, 56.7 ± 13.2%) who had been admitted to our hospital for worsening CVD. Subjects were followed, and the primary endpoints were cardiovascular hospitalization and cardiovascular death. Receiver operating characteristic analysis produced a cutoff value for life-space assessment (LSA) score for increased risk of cardiovascular hospitalization for two years of 53.0 points (sensitivity, 55.9%; specificity, 82.1%). Kaplan−Meier analysis using this cutoff value revealed that the rates of cardiovascular hospitalization and cardiovascular death were significantly higher in subjects with an LSA score below the cutoff than in those with a score above the cutoff (both p < 0.001). Cox proportional analysis revealed that low LSA score was independently associated with cardiovascular hospitalization (HR, 2.540; 95% CI, 1.135−5.680; p = 0.023) and cardiovascular death (HR, 15.223; 95% CI, 1.689−137.180; p = 0.015), even after adjusting for age, sex, left ventricular ejection fraction, and log-transformed brain natriuretic peptide level. Thus, life-space activities are associated with prognosis in older adults with CVD.

Impaired Balance and Gait Characteristics in Patients With Chronic Heart Failure

BACKGROUND AND AIMS

Heart failure affects most systems of the body and causes various problems in patients. Balance deficits and gait deviations can be a result of these effects. There is little information in the literature about balance and gait parameters in chronic heart failure (CHF). This study aimed to investigate balance abnormalities together with gait deficits for possible associations in patients with CHF and compare them to healthy controls.

METHODS

Twenty-two (22) patients with CHF (59±2.5 years) and 22 age- and gender-matched healthy subjects (59.4±6.8 years) participated in the study. This study is a cross-sectional/comparison study. Balance was evaluated using the Activity-Specific Balance Confidence Scale (ABC) and the Mini-Balance Evaluation Systems Test (Mini-BESTest) balance battery, which includes the timed up-and-go test (TUG) and dual-task TUG. Gait analysis was performed using a Biodex Gait Trainer. Peripheral muscle strength (quadriceps muscle and handgrip strength) was assessed using a hand dynamometer and exercise capacity using the six-minute walk test (6MWT).

RESULTS

The CHF patients had significantly lower Mini-BESTest total, reactive postural control, and gait stability scores, significantly longer TUG/dual-task TUG time, and lower ABC score compared to the healthy control group (p<0.05). Chronic heart failure patients also showed significantly lower gait speed, stride length, gait cycle and step length (p<0.05). Dominant-side quadriceps muscle and handgrip strength and 6MWT distance were significantly reduced in CHF (p<0.05). Anticipatory postural adjustments and sensory orientation did not differ between groups.

CONCLUSIONS

Our study demonstrated impaired balance and gait performance and reduced muscle strength and exercise capacity in patients with CHF. Cardiac rehabilitation including balance and walking training should be planned for CHF patients to eliminate balance disorders, gait impairment and prevent falls in this patient group.

Life-Space Mobility and Parkinson's Disease. A Multiple-Methods Study

Background

Life-space mobility (LSM) captures a broad spectrum of mobility in physical and social environments; however, it has not been extensively studied in Parkinson's disease. Using a multiple-methods approach, individual, social and environmental factors that impact LSM were explored in PD.

Methods

Two hundred twenty-seven participants with PD (n = 113) and a comparative group without PD (n = 114) were recruited from the community. Within a cross-sectional survey, LSM (University of Alabama Birmingham Life-Space Assessment, LSA) was compared in the two groups. Using multiple linear regression, socio-demographics, lifestyle behaviors, medical, mobility and social factors were examined to identify factors that explained LSM. A qualitative narrative inquiry was completed to augment the findings from the survey; 10 participants with PD were interviewed regarding facilitators and barriers to mobility.

Results

The mean overall LSA-composite score for the PD group was 64.2 (SD = 25.8) and 70.3 (SD = 23.1) for the community comparative group (mean difference = 6 points, 95%CI:-0.4, 12.5) indicating most participants moved independently beyond their neighborhoods. A higher proportion of the PD group required assistance with mobility than the community comparison group. Not driving, receiving caregiving, lower social participation, and lower monthly family finances were associated with restricted LSM in the PD group. Data from qualitative interviews supported quantitative findings and offered insights into the features of the built environment that facilitate and restrict mobility.

Conclusion

Individual, social and environmental factors are associated with the LSM among persons with PD. Clinicians and policy-makers should include both individual and community-based factors when developing interventions to encourage the LSM of the PD population.

Trajectories of frailty, physical function, and physical activity levels in elderly patients with heart failure: impacts of interruption and resumption of outpatient cardiac rehabilitation due to COVID-19

During the nationwide state of emergency, many hospitals could not provide outpatient cardiac rehabilitation for cardiac disease patients in order to minimize coronavirus disease 2019 (COVID-19) incidence. The purpose of this study was to examine the trajectories of frailty, physical function and physical activity levels due to interruption and resumption of outpatient cardiac rehabilitation by COVID-19 in elderly heart failure patients. Fifteen patients who did not attend outpatient cardiac rehabilitation during the state of emergency but resumed it after the state of emergency were included. Frailty, physical function and physical activity levels were assessed with the Kihon checklist (KCL), various tests including short physical performance battery (SPPB), and life space assessment (LSA), respectively. Objective parameters were measured at three points; before and after the nationwide state of emergency in Japan and 3 months after resuming outpatient cardiac rehabilitation. The post-state of emergency KCL score was significantly higher than the pre-state of emergency score (P = 0.03), whereas there was no significant difference in KCL between post-state of emergency and 3 months after cardiac rehabilitation resumption. SPPB and LSA scores did not change significantly between pre- and post-state of emergency. The changes in LSA from post-state of emergency to 3 months after cardiac rehabilitation resumption tended to correlate with changes in KCL (r = -0.71, P = 0.11). We demonstrated that frailty status deteriorated significantly in elderly heart failure patients whose outpatient cardiac rehabilitation was interrupted due to COVID-19. In addition, the frailty status showed no significant improvement after 3 months of resuming cardiac rehabilitation.

Short physical performance battery score and driving a car are independent factors associated with life-space activities in older adults with cardiovascular disease

AIM

Decreased use of life spaces, as reflected in decreased Life-Space Assessment (LSA) scores, is associated with poor prognosis in older adults. The purpose of this study was to examine factors affecting the extent of life-space activities in older adults with cardiovascular disease.

METHODS

We carried out a prospective observational study in 98 older adults (minimum age 65 years; mean age 79.5 ± 7.4 years) who were admitted to our hospital due to cardiovascular disease. Once their medical condition was stable, they underwent cardiopulmonary exercise testing, echocardiography and physical evaluation, and completed questionnaires.

RESULTS

The LSA score was significantly associated with the ability to drive a car (driving 95.1 ± 21.1 points, not driving 60.4 ± 30.3 points, P < 0.001). In addition, LSA was significantly correlated with age; peak VO₂ ; brain natriuretic peptide; and Short Physical Performance Battery, Geriatric Depression Scale and Mini-Mental State Examination scores. In a multiple regression analysis, Short Physical Performance Battery and driving a car were significantly associated with LSA (β = 0.28, β = 0.37, respectively).

CONCLUSION

Assessment of motor function and social factors in addition to clinical cardiac function might be important to understand the complete context of life-space activity in older adults with cardiovascular disease. Geriatr Gerontol Int 2021; ••: ••-••.

Life-space mobility and healthcare costs and utilization in older men

OBJECTIVES

To determine the association of life-space score with subsequent healthcare costs and utilization.

DESIGN

Prospective cohort study (Osteoporotic Fracture in Men [MrOS]).

SETTING

Six U.S. sites.

PARTICIPANTS

A total of 1555 community-dwelling men (mean age 79.3 years; 91.5% white, non-Hispanic) participating in the MrOS Year 7 (Y7) examination linked with their Medicare claims data.

MEASUREMENTS

Life-space during the past month was assessed as 0 (daily restriction to one's bedroom) to 120 (daily trips outside one's town without assistance) and categorized (0-40, 41-60, 61-80, 81-100, 101-120). Total annualized direct healthcare costs and utilization were ascertained during 36 months after the Y7 examination.

RESULTS

Mean total annualized costs (2020 U.S. dollars) steadily increased across category of life-space score, from $7954 (standard deviation [SD] 16,576) among men with life-space scores of 101-120 to $26,430 (SD 28,433) among men with life-space scores of 0-40 (p < 0.001). After adjustment for demographics, men with a life-space score of 0-40 versus men with a life-space score of 101-120 had greater mean total costs (cost ratio [CR] = 2.52; 95% confidence interval [CI] = 1.84-3.45) and greater risk of subsequent hospitalization (odds ratio [OR] 4.72, 95% CI 2.61-8.53) and skilled nursing facility (SNF) stay (OR 7.32, 95% CI 3.65-14.66). Life-space score was no longer significantly associated with total healthcare costs (CR for 0-40 vs 101-120 1.29; 95% CI 0.91-1.84) and hospitalization (OR 1.76, 95% CI 0.89-3.51) after simultaneous consideration of demographics, medical factors, self-reported health and function, and the frailty phenotype; the association of life-space with SNF stay remained significant (OR 2.86, 95% CI 1.26-6.49).

CONCLUSION

Our results highlight the importance of function and mobility in predicting future healthcare costs and suggest the simple and convenient life-space score may in part capture risks from major geriatric domains and improve identification of older, community-dwelling men likely to require costly care.

Validation of the German Life-Space Assessment (LSA-D): cross-sectional validation study in urban and rural community-dwelling older adults

OBJECTIVES

To develop a German version of the original University of Alabama at Birmingham Study of Aging Life-Space Assessment (LSA-D) for measurement of community mobility in older adults within the past 4 weeks and to evaluate its construct validity for urban and rural populations of older adults.

DESIGN

Cross-sectional validation study.

SETTING

Two study centres in urban and rural German outpatient hospital settings.

PARTICIPANTS

In total, N=83 community-dwelling older adults were recruited (n=40 from urban and n=43 from rural areas; mean age was 78.5 years (SD=5.4); 49.4% men).

PRIMARY AND SECONDARY OUTCOME MEASURES

The final version of the translated LSA-D was related to limitations in activities and instrumental activities of daily living (ADL/iADL) as primary outcome measure (primary hypothesis); and with sociodemographic factors, functional mobility, self-rated health, balance confidence and history of falls as secondary outcome measures to obtain construct validity. Further descriptive measurements of health included hand grip strength, screening of cognitive function, comorbidities and use of transportation. To assess construct validity, correlations between LSA-D and the primary and secondary outcome measures were examined for the total sample, and urban and rural subsamples using bivariate regression and multiple adjusted regression models. Descriptive analyses of LSA-D included different scoring methods for each region. All parameters were estimated using non-parametric bootstrapping procedure.

RESULTS

In the multiple adjusted model for the total sample, number of ADL/iADL limitations (β=-0.26; 95% CI=-0.42 to -0.08), Timed Up and Go Test (β=-0.37; 95% CI=-0.68 to -0.14), shared living arrangements (β=0.22; 95% CI=0.01 to 0.44) and history of falls in the past 6 months (β=-0.22; 95% CI=-0.41 to -0.05) showed significant associations with the LSA-D composite score, while living in urban area (β=-0.19; 95% CI=-0.42 to 0.03) and male gender (β=0.15; 95% CI=-0.04 to 0.35) were not significant.

CONCLUSION

The LSA-D is a valid tool for measuring life-space mobility in German community-dwelling older adults within the past 4 weeks in ambulant urban and rural settings.

TRIAL REGISTRATION NUMBER

DRKS00019023.

Transitional care from skilled nursing facilities to home: study protocol for a stepped wedge cluster randomized trial

Background

Skilled nursing facility (SNF) patients are medically complex with multiple, advanced chronic conditions. They are dependent on caregivers and have experienced recent acute illnesses. Among SNF patients, the rate of mortality or acute care use is over 50% within 90 days of discharge, yet these patients and their caregivers often do not receive the quality of transitional care that prepares them to manage serious illnesses at home.

Methods

The study will test the efficacy of Connect-Home, a successfully piloted transitional care intervention targeting seriously ill SNF patients discharged to home and their caregivers. The study setting will be SNFs in North Carolina, USA, and, following discharge, in patients’ home. Using a stepped wedge cluster randomized trial design, six SNFs will transition at randomly assigned intervals from standard discharge planning to the Connect-Home intervention. The SNFs will contribute data for patients (N = 360) and their caregivers (N = 360), during both the standard discharge planning and Connect-Home time periods. Connect-Home is a two-step intervention: (a) SNF staff create an individualized Transition Plan of Care to manage the patient’s illness at home; and (b) a Connect-Home Activation RN visits the patient’s home to implement the written Transition Plan of Care. A key feature of the trial includes training of the SNF and Home Care Agency staff to complete the transition plan rather than using study interventionists. The primary outcomes will be patient preparedness for discharge and caregiver preparedness for caregiving role. With the proposed sample and using a two-sided test at the 5% significance level, we have 80% power to detect a 18% increase in the patient’s preparedness for discharge score. We will employ linear mixed models to compare observations between intervention and usual care periods to assess primary outcomes. Secondary outcomes include (a) patients’ quality of life, functional status, and days of acute care use and (b) caregivers’ burden and distress.

Discussion

Study results will determine the efficacy of an intervention using existing clinical staff to (a) improve transitional care for seriously ill SNF patients and their caregivers, (b) prevent avoidable days of acute care use in a population with persistent risks from chronic conditions, and (c) advance the science of transitional care within end-of-life and palliative care trajectories of SNF patients and their caregivers. While this study protocol was being implemented, the COVID-19 pandemic occurred and this protocol was revised to mitigate COVID-related risks of patients, their caregivers, SNF staff, and the study team. Thus, this paper includes additional material describing these modifications.

Trial registration

ClinicalTrials.gov NCT03810534. Registered on January 18, 2019.

Falls and life-space mobility: longitudinal analysis from The International Mobility in Aging Study

OBJECTIVES

To investigate a 4-year longitudinal relationship between falls, recurrent falls, and injurious falls, according to different levels of life-space mobility (LSM).

METHODS

Longitudinal analysis of an international cohort study. The participants were older adults from the International Mobility in Aging Study (IMIAS) aged between 65 and 74 years at baseline. Three waves of data (2012, 2014, 2016) were used. Fall history during the past year was recorded. Recurrent fallers were identified as those who fell at least twice and injurious fallers as participants who required medical attention. LSM measurements included Total Life-Space (LS-C), Maximal Life-Space (LS-M), Assisted Life-Space (LS-A), Independent Life-Space (LS-I) and Restricted Life-space (LS-ID) scores. Generalized estimation equation (GEE) models were used to determine whether life-space mobility measures and their change over time differed between recurrence of falls and injurious falls.

RESULTS

At baseline, the prevalence of falls in the last year was 28%. 11.8% reported recurrent falls and 2.6% had serious injurious falls in the last year preceding the assessments. Recurrent fallers were more likely to be female, with insufficient income and, with comorbidities. GEE models showed that life-space mobility was lower among those with recurrent falls or serious injurious falls compared to those who never fell, but the rate of change did not differ over the 4-year follow-up except for the LS-A and LS-I scores, where some improvements were observed over time.

CONCLUSIONS AND IMPLICATIONS

Falls were independently associated with a decrease in LSM over 4 years. Targeting older adults with recurrent and injurious falls with appropriate interventions may improve community mobility and social participation.

Effects of the Cardiac and Comorbid Conditions Heart Failure (3C-HF) Score at Admission on Life Space at Three Months after Hospital Discharge in Elderly Patients with Heart Failure: A Short Report

We assessed 22 elderly patients with heart failure, 3 months after hospital discharge. We examined and compared factors that predict small life space after discharge with the same factors before discharge. Life-Space Assessment was used to classify the participants as either having “small living spaces” or “large living spaces”. We collected data regarding characteristics, Cardiac and Comorbid Conditions Heart Failure Score (3C-HF score), and evaluated motor function. We also collected data on the patients’ lifestyle habits. We investigated spreading life space at 3 months after discharge by mailing a questionnaire to the subjects. Using multiple logistic regression analysis, we were able to predict the patients having a small life space at 3 months after discharge by the Cardiac and Comorbid Conditions Heart Failure (3C-HF) score (odds ratio, 1.19; 95% confidence interval, 1.01–1.39; p = 0.038) at admission. Overall, the 3C-HF score at admission may be associated with the size of life space at 3 months after hospital discharge in elderly patients with heart failure. Future multicenter studies should be conducted to validate the results of this study by measuring post-discharge activity with a more objective index.

Life-Space Mobility in Parkinson's Disease: Associations with Motor and Non-Motor Symptoms

BACKGROUND

To describe life-space mobility and explore associations of motor and non-motor symptoms with life-space mobility in people with Parkinson's disease (PD).

METHODS

About 164 community-dwelling persons with PD (mean age 71.6 years, 64.6% men) received a postal survey and a subsequent home visit. Motor assessments included perceived walking difficulties (Walk-12G), mobility (Timed Up and Go test), motor symptoms (UPDRS-III), and freezing of gait (item 3, FOG-Qsa). Non-motor symptoms included depressive symptoms (GDS-15), pain, fatigue (NHP-EN), and global cognition (MoCA). Life-space mobility was assessed with the life-space assessment (LSA). Calculations included composite score (range 0-120; higher indicating better life-space mobility), independent life-space (range 0-5), assisted life-space (range 0-5), and maximal life-space (range 0-5). Associations were analyzed with linear regression models, adjusted for age, sex, and PD severity (Hoehn and Yahr).

RESULTS

Mean life-space mobility score was 72.3 (SD = 28.8). Almost all participants (90%) reached the highest life-space level (beyond town). Half of these reached this level independently, while one-third were unable to move outside their bedroom without assistive devices or personal help. When adjusted for confounders, depressive symptoms, pain, and perceived walking difficulties was negatively associated with life-space mobility. In the multivariable model, only perceived walking difficulties were associated with life-space mobility.

CONCLUSIONS

Our findings indicate that perceived walking difficulties should be targeted to maintain or improve life-space mobility in people with PD. Depressive symptoms and pain may also merit consideration. More research is needed to elucidate the role of environmental and personal factors for life-space mobility in PD.

A National Study of U.S. Emergency Departments: Racial Disparities in Hospitalizations for Heart Failure

INTRODUCTION

Racial disparities in heart failure hospitalizations are well documented. The majority of heart failure hospitalizations originate from emergency departments, but emergency department hospitalization patterns for heart failure and the factors that influence hospitalization are poorly understood. This gap in knowledge was examined using a nationally representative sample of emergency department visits for heart failure.

METHODS

National Hospital Ambulatory Medicare Care Survey data on 2001-2010 emergency department visits were analyzed in 2015-2017 to examine age-related racial differences in hospitalization patterns for heart failure, using multivariable modified Poisson regression models.

RESULTS

More than 12million adult visits for heart failure to U.S. emergency departments occurred from 2001 to 2010, with 23% of visits by blacks. Overall, 71% of visits resulted in hospitalization (57% to floor beds and 14% to intensive care units). Among floor admissions for higher clinical acuity visits, whites were more likely than blacks to be hospitalized. Whites with higher clinical acuity were more likely to be hospitalized than those with lower clinical acuity (71% vs 63%, p=0.005). This expected pattern was not observed in blacks, particularly those aged ≥65years, who were hospitalized in 71% of lower clinical acuity visits, but only 61% of higher acuity visits. Among adults aged ≥65years, there was a significant interaction between clinical acuity Xrace with regard to hospitalization (p=0.037).

CONCLUSIONS

These results suggest age and racial disparities in hospitalization rates for emergency department patients with heart failure. The reasons for these disparities in hospitalization are unclear. Further studies on emergency department hospitalization decisions, and the impact of emergency department clinical factors, may help clarify this finding.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled African American Men's Health: Research, Practice, and Policy Implications, which is sponsored by the National Institutes of Health.

Contextual factors associated with life-space mobility in community-dwelling older adults based on International Classification of Functioning, Disability and Health: protocol for a systematic review

INTRODUCTION

Mobility decline compromises functionality and quality of life in old age. Life-Space Assessment (LSA) evaluates mobility considering interaction between person and environment. The International Classification of Functioning, Disability and Health (ICF) is a reference to identify and categorise the personal and environmental contextual factors associated to the LSA. Our objective is identifying contextual factors that may influence life-space mobility of older community-dwelling adults based on ICF.

METHODS AND ANALYSIS

A systematic review of literature will be performed to identify studies published between 1 January 2001 and 10 May 2017 which investigates life-space mobility among older adults. Keywords will be entered into the electronic databases of MEDLINE (PubMed), EMBASE (OVID), CINHAL (EBSCO), Cochrane Central Register of Controlled Trials Cochrane Central (OVID), PsycINFO (EBSCO) and COCH (OVID). Five investigators will work on search databases and standardised screening of the articles. Mobility predictors will be separated into personal and environmental aspects, according to the ICF model. The results will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, and then a meta-analysis will be performed, if applicable.

DISCUSSION

Knowledge about life-space mobility in community-dwelling older adults by examining related risk and protective aspects may help practitioners better approach older adults' mobility and prevent their decline in old age. Furthermore, researchers will have more clues for investigations into factors related to life-space mobility.

TRIAL REGISTRATION NUMBER

CRD42017064552.

Life-Space mobility and clinical outcomes in COPD

Background

Social isolation is a common experience in patients with COPD but is not captured by existing patient-reported outcomes, and its association with clinical outcomes is unknown.

Methods

We prospectively enrolled adults with stable COPD who completed the University of Alabama at Birmingham Life Space Assessment (LSA) (range: 0–120, restricted Life-Space mobility: ≤60 and a marker of social isolation in older adults); six-minute walk test (6MWT), and the University of California at San Diego Shortness of Breath Questionnaire, COPD Assessment Test, and Hospital Anxiety and Depression Scale. The occurrence of severe exacerbations (emergency room visit or hospitalization) was recorded by review of the electronic record up to 1 year after enrollment. We determined associations between Life-Space mobility and clinical outcomes using regression analyses.

Results

Fifty subjects had a mean ± SD %-predicted FEV₁ of 42.9±15.5, and 23 (46%) had restricted Life-Space mobility. After adjusting for age, gender, %-predicted FEV₁, comorbidity count, inhaled corticosteroid/long-acting beta₂-agonist use, and prior cardiopulmonary rehabilitation, subjects with restricted Life-Space had an increased risk for severe exacerbations (adjusted incidence rate ratio 4.65, 95% CI 1.19–18.23, P=0.03). LSA scores were associated with 6MWD (R=0.50, P<0.001), dyspnea (R=−0.58, P<0.001), quality of life (R=−0.34, P=0.02), and depressive symptoms (R=−0.39, P=0.005).

Conclusion

Restricted Life-Space mobility predicts severe exacerbations and is associated with reduced exercise tolerance, more severe dyspnea, reduced quality of life, and greater depressive symptoms.

Task Modifications in Walking Postpone Decline in Life-Space Mobility Among Community-Dwelling Older People: A 2-year Follow-up Study

Background

Task modification refers to performing a task differently than before. While task modification in walking may be a sign of looming walking difficulty, it may also be adaptive in and postpone the decline in life-space mobility. However, this has not been studied. This study examined whether changes in life-space mobility over a 2-year period differ between people who at baseline report no walking difficulty and no task modification, those who report no walking difficulty but task modification, and those who report walking difficulty.

Methods

Community-dwelling people aged 75-90 years were interviewed face-to-face at baseline (N = 848), and over phone one (n = 816) and two (n = 761) years later. Life-space mobility was assessed annually with the Life-Space Assessment (range 0-120, higher scores indicate better life-space mobility). Self-reported ability to walk 2 km was assessed at baseline and categorized into "no difficulty," "no difficulty but task modifications" (reduced frequency, given up walking, walking slower or resting during walking) and "difficulty." The analyses were adjusted for age, gender, number of chronic conditions, cognitive impairment, lower extremity performance and education.

Results

The life-space mobility score was highest and remained stable over 2-years among those with no walking difficulties at baseline and lowest and showing a steady decline among those with walking difficulties. Those with task modifications formed the middle group. They showed no marked changes in life-space mobility during the first year, but significant decline during the second year.

Conclusion

Task modifications in walking may help community-dwelling older people to postpone life-space mobility decline.

Life-Space Predicts Health Care Utilization in Community-Dwelling Older Adults

OBJECTIVE

To determine whether decline in life-space mobility predicts increased health care utilization among community-dwelling older adults.

METHOD

Health care utilization (number of emergency department [ED] visits and hospitalizations) was self-reported during monthly interviews among 419 community-dwelling African American and non-Hispanic White adults aged 75 years and older in The University of Alabama at Birmingham (UAB) Study of Aging II. Life-space was measured using the UAB Life-Space Assessment. Generalized estimating equations were used to examine associations of life-space at the beginning of each interval with health care utilization over the 1-month interval.

RESULTS

Overall, 400 participants were followed for 36 months. A 10-point decrease in life-space was associated with 14% increased odds of an ED visit and/or hospitalization over the next month, adjusting for demographics, transportation difficulty, comorbidity, and having a doctor visit in the last month.

DISCUSSION

Life-space is a practical alternative in predicting future health care utilization to performance-based measures, which can be difficult to incorporate into clinical or public health practice.

Neighborhood Disadvantage and Life-Space Mobility Are Associated with Incident Falls in Community-Dwelling Older Adults

OBJECTIVES

To determine the relationship between neighborhood-level socioeconomic characteristics, life-space mobility, and incident falls in community-dwelling older adults.

DESIGN

Prospective, observational cohort study with a baseline in-home assessment and 6-month telephone follow-up.

SETTING

Central Alabama.

PARTICIPANTS

Community-dwelling adults aged 65 and older recruited from a random sample of Medicare beneficiaries (N = 1,000).

MEASUREMENTS

Neighborhood disadvantage was measured using a composite index derived from baseline neighborhood-level residential census tract socioeconomic variables. Data on individual-level socioeconomic characteristics, clinical variables, and life-space collected at baseline were included as covariates in a multivariate model using generalized estimating equations to assess the association with incident falls in the 6 months after baseline.

RESULTS

Of the 940 participants who completed baseline and follow-up assessments, 126 (13%) reported one or more new falls in the 6 months after baseline. There was an independent nonlinear association between neighborhood disadvantage (according to increasing quartiles of disadvantage) and incident falls after adjusting for confounders: The lowest quartile served as reference; 2nd quartile odds ratio (OR) = 2.4, 95% confidence interval (CI) = 1.2-4.6; 3rd quartile OR = 1.9, 95% CI = 1.0-3.7; 4th quartile OR = 3.2, 95% CI = 1.7-6.0. Each 10-point decrement in life-space (OR = 1.2, 95% CI = 1.0-1.3) was associated with a higher risk of falls.

CONCLUSION

Greater neighborhood disadvantage was associated with greater risk of falls. Life-space also contributes separately to fall risk. Community-dwelling older adults in disadvantaged neighborhoods, particularly those with limited mobility, may benefit from a more-rigorous assessment of their fall risk by healthcare providers. Neighborhood level socioeconomic characteristics should also be an important consideration when identifying vulnerable populations that may benefit the most from fall prevention programs.

Impact of Emergency Department Visits and Hospitalization on Mobility Among Community-Dwelling Older Adults

PURPOSE

The study purpose was to assess the effects of emergency department visits on mobility as measured by Life-Space Assessment (LSA) scores and to compare life-space trajectories associated with emergency department visit only, hospitalization, and no event.

METHODS

A total of 410 community-dwelling adults aged ≥75 years who were living in the community, were able to communicate by telephone, could schedule an in-home interview, and could answer questions independently were followed from June 2010 to August 2014. In-home baseline and monthly telephone follow-up interviews collected data on LSA scores, emergency department use, and hospitalizations. Life-space is measured using a validated patient-reported tool reflecting community mobility and quality of life. Trajectories of LSA before and after an emergency department visit or hospitalization were compared with no event occurrence.

RESULTS

Mean age of participants was 81.7 years (standard deviation, 4.8); 57% were female, and 35% were African American. During 3 years of follow-up, 83 persons (20%) had an emergency department visit without subsequent hospitalization and 164 persons (40%) were hospitalized. Although baseline LSA scores were similar, in the month after an emergency department visit, adjusted LSA scores decreased by 6.1 points (P = .01) in comparison with hospitalized participants who experienced an average decrease of 18.0 points (P < .0001). Neither those with an emergency department visit only nor those with hospitalization recovered to their prior level of community mobility. Moreover, those with an emergency department visit showed no significant improvement in LSA scores up to 1 year later.

CONCLUSIONS

Older adults who experienced an emergency department visit or hospitalization had an associated decrease in community mobility without significant recovery.