Identifying hospitalized older patients at varying risk for physical performance decline: a new approach

Functional decline after surgery in older patients with head and neck cancer

INTRODUCTION

In addition to classical endpoints such as survival and complication rates, other outcomes such as quality of life and functional status are increasingly recognized as important endpoints, especially for elderly patients. However, little is known about the long-term effect of surgery with regard to these other outcomes. Our aim is to investigate the functional status and self-reported health status of patients ≥ 70 years one year after surgery for head and neck cancer.

METHODS

We present one-year follow-up data of patients ≥ 70 year who underwent surgery for HNC. During an interview by telephone, functional status was evaluated by using the Katz-15 Index of Independence questionnaire including six items covering basic Activities of Daily Living (ADL) and nine items covering Instrumental Activities of Daily Living (IADL). Measurements were compared with those obtained preoperatively.

RESULTS

In total, 126 patients were included and eventually we collected follow-up data of 68 patients. There was a statistically significant decrease in functional status on the total Katz-15 and on the IADL questionnaire scores one year after surgery (mean 1.34 versus 2.42,p-value 0.00 and mean 1.21 versus 1.94,p-value 0.00). There was no significant change concerning ADL dependence (p-value 0.18) and cognitive status (p-value 0.11). The self-reported health status improved postoperatively, although not statistically significantly so (mean 67.36 versus 71.25,p-value 0.12).

CONCLUSION

Approximately-one year after surgery for HNC, there is a significant decline in functional status indicating a higher level of dependency.

Early Identification of Risk Factors for Mobility Decline Among Hospitalized Older Patients

OBJECTIVE

The aim of the study was to identify the risk factors for mobility decline among hospitalized older patients early.

DESIGN

This is a prospective cohort study. A total of 875 older patients were divided into two groups: older patients with and without mobility decline. The mobility level was measured using the item of functional mobility in the Geriatric Screening for Care 10. The change in mobility between admission and discharge was determined as the dependent variable. There were a total of 18 independent variables, which consisted of three demographic variables, 10 most problematic domains of geriatric care, and five other health-related variables. A multivariable logistic regression analysis was conducted to identify the risk factors for mobility decline during hospitalization.

RESULTS

Of the 875 older patients, 135 (15.4%) experienced mobility decline during hospitalization. The multivariable logistic regression analysis revealed female sex, cognitive impairment, and underweight as the risk factors for mobility decline during hospitalization.

CONCLUSIONS

The identified risk factors should be considered to identify patients at a risk of mobility decline early and to provide targeted interventions, which can prevent mobility decline.

Identifying effective and feasible interventions to accelerate functional recovery from hospitalization in older adults: A randomized controlled pilot trial

Hospitalization induces functional decline in older adults. Many geriatric patients fail to fully recover physical function after hospitalization, which increases the risk of frailty, disability, dependence, re-hospitalization, and mortality. There is a lack of evidence-based therapies that can be implemented following hospitalization to accelerate functional improvements. The aims of this Phase I clinical trial are to determine 1) the effect size and variability of targeted interventions in accelerating functional recovery from hospitalization and 2) the feasibility of implementing such interventions in community-dwelling older adults. Older patients (≥65years, n=100) will be recruited from a single site during hospitalization for an acute medical condition. Subjects will be randomized to one of five interventions initiated immediately upon discharge: 1. protein supplementation, 2. in-home rehabilitation plus placebo supplementation, 3. in-home rehabilitation plus protein supplementation, 4. single testosterone injection, or 5. isocaloric placebo supplementation. Testing will occur during hospitalization (baseline) and at 1 and 4weeks post-discharge. Each testing session will include measures of muscle strength, physical function/performance, body composition, and psychological function. Physical activity levels will be continuously monitored throughout study participation. Feasibility will be determined through collection of the number of eligible, contacted, and enrolled patients; intervention adherence and compliance; and reasons for declining enrollment and study withdrawal. This research will determine the feasibility of post-hospitalization strategies to improve physical function in older adults. These results will also provide a foundation for performing larger, multi-site clinical trials to improve physical function and reduce readmissions in geriatric patents.

Optimizing physical activity among older adults post trauma: Overcoming system and patient challenges

BACKGROUND

By 2050 it is anticipated that close to half (40%) of all trauma patients will be over the age of 65. Recovery for these individuals is more complicated than among younger individuals. Early mobilization has been shown to improve outcomes. Unfortunately, there are many challenges to early mobilization. The Function Focused Care Intervention was developed to overcome these challenges.

PURPOSE

The purpose of this paper was to describe the initial recruitment of the first 25 participants and delineate the challenges and successes associated with implementation of this intervention.

RESULTS

Overall recruitment rates were consistent with other studies and the intervention was implemented as intended. Most patients were female, white and on average 79 years of age. Optimizing physical activity of patients was a low priority for the nurses with patient safety taking precedence. Patients spent most of the time in bed. Age, depression and tethering were the only factors that were associated with physical activity and functional outcomes of patients.

CONCLUSION

Ongoing work is needed to keep patients physically active in the immediate post trauma recovery period.

Exposure to therapy of older patients with trauma and factors that influence provision of therapy

BACKGROUND

Rehabilitation as soon as possible after trauma decreases sedentary behavior, deconditioning, length of stay, and risk of rehospitalization.

OBJECTIVE

The study objectives were to describe exposure of older patients with trauma to rehabilitation and to explore factors associated with the number and initiation of therapy sessions.

DESIGN

This was a retrospective study of data from electronic medical records.

METHODS

Randomly selected older patients with trauma were described with regard to demographics, trauma diagnoses, comorbidities, preadmission function, and exposure to therapy. Regression analyses explored factors associated with number of therapy sessions and days until therapy was ordered and completed.

RESULTS

Records for 137 patients were randomly selected from records for 1,387 eligible patients who had trauma and were admitted over a 2-year period to a level I trauma center. The 137 patients received 303 therapy sessions. The sample included 63 men (46%) and 74 women (54%) who were 78 (SD=10) years of age; most patients were white (n=115 [84%]). All patients had orders for therapy, although 3 patients (2%) were never seen. An increase in comorbidities was associated with an increase in therapy sessions, a decrease in the number of days until an order was written, but an increase in the number of days from admission to evaluation. Injury severity was associated with a decrease in the number of days from admission to an order being written. A postponed or canceled therapy session was associated with increases in the number of days from admission to evaluation and in the number of days from an order being written to evaluation.

LIMITATIONS

This study was a retrospective review of a small sample with subjective measures and several dichotomous variables.

CONCLUSIONS

Increased injury severity, increased numbers of comorbidities, and postponed or canceled therapy sessions were associated with decreased time from admission to therapy orders, increased time from admission and orders to evaluation, and increased number of therapy sessions.

A systematic review of mobility instruments and their measurement properties for older acute medical patients

BACKGROUND

Independent mobility is a key factor in determining readiness for discharge for older patients following acute hospitalisation and has also been identified as a predictor of many important outcomes for this patient group. This review aimed to identify a physical performance instrument that is not disease specific that has the properties required to accurately measure and monitor the mobility of older medical patients in the acute hospital setting.

METHODS

Databases initially searched were Medline, Cinahl, Embase, Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials without language restriction or limits on year of publication until July 2005. After analysis of this yield, a second step was the systematic search of Medline, Cinahl and Embase until August 2005 for evidence of the clinical utility of each potentially suitable instrument. Reports were included in this review if instruments described had face validity for measuring from bed bound to independent levels of ambulation, the items were suitable for application in an acute hospital setting and the instrument required observation (rather than self-report) of physical performance. Evidence of the clinical utility of each potentially suitable instrument was considered if data on measurement properties were reported.

RESULTS

Three instruments, the Elderly Mobility Scale (EMS), Hierarchical Assessment of Balance and Mobility (HABAM) and the Physical Performance Mobility Examination (PPME) were identified as potentially relevant. Clinimetric evaluation indicated that the HABAM has the most desirable properties of these three instruments. However, the HABAM has the limitation of a ceiling effect in an older acute medical patient population and reliability and minimally clinically important difference (MCID) estimates have not been reported for the Rasch refined HABAM. These limitations support the proposal that a new mobility instrument is required for older acute medical patients.

CONCLUSION

No existing instrument has the properties required to accurately measure and monitor mobility of older acute medical patients.

Outcomes at 12 months in a population of elderly patients discharged from a rehabilitation unit

OBJECTIVES

This study investigates the cognitive, functional, and clinical variables associated with the risk of institutionalization, rehospitalization, and death at 12 months among a population of elderly discharged from a Rehabilitation and Aged Care Unit (RACU) within a 1-year period (May 1, 2004 to April 30, 2005). The RACU is a relatively new setting of care providing intensive rehabilitation and clinical support to elderly with highly heterogeneous reasons for admission.

METHODS

There were 1303 patients (> or =65 years old) contacted 12 months after discharge from the RACU. We obtained information about institutionalization, rehospitalization, and death. Predictors were all the demographic and clinical variables potentially related to these outcomes. The relationship among predictors and outcomes was tested with multiple stepwise logistic regression models.

RESULTS

Among the 1072 patients alive at the 12-month follow-up, 90 (8.4%) were institutionalized (3.4% early at discharge and 4.9% within the next period). The logistic regression analysis showed that 2 ranges of age (78 to 83 years and 84 years or more), living alone, occurrence of delirium, cognitive impairment (Mini Mental State Examination lower or equal to 20/30), and poor functional status at discharge (Barthel Index scores ranging from 69 to 85 and Barthel Index scores lower than 68/100) were independently and significantly associated with the risk of institutionalization during the 12 months following discharge from the RACU. Three hundred and twenty-three (30.1%) patients had been rehospitalized once and 86 (8.0%) patients twice at the 12-month follow-up. In the multivariate analysis, comorbidity (Charlson Index scores ranging from 2 to 3 and Charlson Index scores higher than 4) and delirium were significantly and independently associated with this outcome. One hundred and thirty-six (11.3%) patients had died by the 12-month follow-up. The stepwise logistic regression analysis showed that age greater than 83 years, poor functional status (Barthel Index lower than 60/100 at discharge), high comorbidity (Charlson Index scores ranging from 3 to 4 and Charlson Index scores higher than 4, respectively), and albumin serum levels ranging from 3.2 to 2.9 mg/dL and lower than 2.9 mg/dL independently and significantly predicted the 12-month risk of death. Absence of depressive symptoms (Geriatric Depression Scale <2/15) had instead a protective effect.

CONCLUSION

Variables related to the sociodemographic, cognitive, functional, and health status predicted, with different degree of association, the 12-month risk of institutionalization, rehospitalization, and death among a population of elderly patients discharged from a RACU. Accordingly, various clinical and organizational approaches may be planned for prevention.

Cultivating responsive systems for the care of acutely and critically ill older adults

This article examines the importance of creating acute care systems that are responsive to the needs of acutely and critically ill and injured older adults. Four attributes of the responsive system are examined: elasticity, enabling, ease, and equanimity. An analytic literature review provides the basis for recommended practices by responsive professionals in responsive systems. Implications for practice, research, education, and policy are provided.

Upper extremity function, an independent predictor of adverse events in hospitalized elderly

OBJECTIVE

To examine the relationships between upper extremity function (UEF) and mortality, need for social assistance and change of residence, at discharge from hospital and at 1 month following discharge.

METHODS

Observational, cohort study.

SETTING

Acute Geriatric Unit of a Tertiary Teaching Hospital.

SUBJECTS

356 Consecutive patients admitted over a 6-month period. Performance of 4 UEF tasks (UEFTs) was assessed by direct observation on admission, at discharge and at 1 month after discharge: picking up a full glass, touching the scapula, cutting with a knife and unfastening a button. UEF was correlated with measures of global physical and mental functioning, namely the Barthel index, the Lawton index, Holden's FAC scale and Pfeiffer's test. The association of UEF with adverse events such as mortality, need for social assistance and change of residence was also assessed.

RESULTS

UEF was well-correlated with global functioning scales (p<0.001). Using multivariant models, the inability to perform 3 or 4 UEFTs on admission was an independent predictor of mortality at discharge (OR 15.2; CI 95% 5.2-44.4) and at 1 month (OR 3.3; CI 95% 1.8-6.2), of need for social assistance at discharge (OR 2.1; CI 95% 1.1-4.1) and at 1 month (OR 3.3; CI 95% 1.1-10.1), and of change of residence at discharge (OR 3.5; CI 95% 1.2-10.4).

CONCLUSIONS

UEF, independently of global functioning, is a predictor of adverse events in the hospitalized elderly. Its determination by direct observation may be an indirect measure of global functioning during hospitalization, avoiding potentially biased data facilitated by caregivers.

Lower limb function as predictor of falls and loss of mobility with social repercussions one year after discharge among elderly inpatients

BACKGROUND AND AIMS

Poor mobility of the lower limbs in community-dwelling elderly people is a predictor of functional decline in terms of disability, falls, nursing home admission, and death. However, its predictive value has not been studied in acute care hospital settings. The aims of this observational, prospective study were: 1) to assess the prognostic value of lower limb function; and 2) to compare the predictive value of three performance tests in elderly inpatients.

METHODS

We studied 144 patients aged 70 or older (60 men and 84 women, mean age 78.7 +/- 5.6 years), admitted consecutively to a general internal medicine ward. Before discharge, patients underwent multidimensional assessment, including static and dynamic equilibrium and gait, by the Performance-Oriented Mobility Assessment (POMA), Short Physical Performance Battery (SPPB), and Functional Reach (FR). One-year outcomes were falls, loss of mobility with social repercussions (inability to leave home, or need for nursing home care) and death.

RESULTS

In univariate analysis, poor results on any of the three tests were associated with an increased risk of falls, loss of mobility with social repercussions, and death. In multivariate analysis, age, two or more falls, and a low POMA score were predictive of future falls, whereas dependency in instrumental activities of daily living and a low SPPB score were predictive of loss of mobility with social repercussions. No multivariate model was superior to univariate ones in predicting death. No associations were found between other medical or geriatric characteristics and outcomes.

CONCLUSIONS

Lower limb mobility tests performed in an acute care hospital setting are predictive of future falls, inability to leave home, and/or need for nursing home care.

Mortality and readmission of the elderly one year after hospitalization for pneumonia

BACKGROUND AND AIMS

Pneumonia, which is common among the elderly, is associated with untoward consequences. We sought, therefore, to describe the incidence of death and readmission, and to determine predictors of these variables during the year subsequent to index hospitalization.

METHODS

This study involved the follow-up of 153 patients surviving an index hospitalization for pneumonia. Death and readmission were documented, and the relationship of selected variables with these outcomes was determined.

RESULTS

Ninety-six (62.6%) of the patients had died or were readmitted. Only a count of comorbidities was correlated significantly with death, readmission, and either death or readmission. Using regression analysis, death alone was predicted by multiple variables. Grip strength and comorbidity counts correctly classified 75.2% of patients relative to that outcome.

CONCLUSIONS

Untoward outcomes are likely among patients surviving acute hospitalization for pneumonia. These outcomes are related to variables that can be targeted in secondary prevention efforts.

Unsteadiness reported by older hospitalized patients predicts functional decline

OBJECTIVES

To determine whether a simple question about steadiness at admission predicts in-hospital functional decline and whether unsteadiness at admission predicts failure of in-hospital functional recovery of patients who have declined immediately before hospitalization.

DESIGN

Prospective cohort study.

SETTING

One university hospital and one community teaching hospital.

PARTICIPANTS

One thousand five hundred fifty-seven hospitalized medical patients aged 70 and older.

MEASUREMENTS

On admission, patients reported their steadiness with walking and whether they could perform independently each of five basic activities of daily living (ADLs) at admission and 2 weeks before admission (baseline). For the primary analysis, the outcome was decline in ADL function between admission and discharge. For the secondary analysis, the outcome was in-hospital recovery to baseline ADL function in patients who experienced ADL decline in the 2 weeks before admission.

RESULTS

In the primary cohort (n = 1,557), 25% of patients were very unsteady at admission; 22% of very unsteady patients declined during hospitalization, compared with 17%, 18%, and 10% for slightly unsteady, slightly steady, and very steady patients, respectively (P for trend =.001). After adjusting for age; medical comorbidities; Acute Physiology, Age, and Chronic Health Evaluation II score; and admission ADL, unsteadiness remained significantly associated with ADL decline (odds for decline for very unsteady compared with very steady = 2.6, 95% confidence interval = 1.5-4.5). In the secondary analysis, predicting ADL recovery in patients who declined before hospitalization (n = 563), 46% of patients were very unsteady at admission. In this cohort, 44% of very unsteady patients failed to recover, compared with 35%, 36%, and 33% for each successively higher level of steadiness, respectively (P for trend = 0.06). After multivariate adjustment, greater unsteadiness independently predicted failure of recovery (P for trend = 0.02).

CONCLUSION

A simple question about steadiness identified patients at increased risk for in-hospital ADL decline and, in patients who lost ADL function immediately before admission, failure to recover.

Extending the Range of Functional Assessment in Older Adults: Development of the Late-Life Function and Disability Instrument

As a preliminary step in developing the physical-functioning measure of the Late-Life Function and Disability Instrument (LLFDI), the authors compared its items with the physical-functioning items (PF-10) on the SF-36 Health Survey. They compared the item coverage, hierarchy, and scale-separation properties of the PF-10 items with those of the physical-functioning items of the LLFDI. Both questionnaires were administered to 50 community-dwelling older adults. A partial-credit, 1-parameter, item-response-theory model was used to scale the items. The LLFDI improved the range of ability of daily activities that was encompassed by the PF-10 items by 46%. By sequentially deleting new items with poor fit to the overall scale and items with redundant content, the authors developed a scale more capable of accurately assessing low-functioning activities. The LLFDI function component incorporates a broader content range and better person and item separation than the PF-10 items. It appears to have potential as a comprehensive functional-activity assessment for community-dwelling older adults.

Predictors of functional decline in hospitalized elderly patients: a systematic review

BACKGROUND

This article will systematically review the methodological characteristics and results of studies of variables and indices that predict functional decline in older hospitalized patients.

METHODS

We restricted this review to original longitudinal studies of predictors of either physical functional decline or nursing home admission among patients aged 60 and older. Two reviewers independently abstracted information on methodological characteristics and substantive results.

RESULTS

Thirty articles were identified, derived from 27 different studies, reporting on 33 substudies. Substantial variability was found with respect to study design, outcomes measured, period of follow-up, predictors investigated, and analytic methods. Multivariable predictive indices were significantly associated with adverse outcomes in the majority of studies that investigated them, as were the following variables: age, diagnosis, activities of daily living, cognitive impairment (including delirium), and residence.

CONCLUSIONS

The methodological heterogeneity of the studies identified limits quantitative synthesis of the results. Predictive indices for hospitalized elders appear to have moderate short-term predictive ability.

Late Life Function and Disability Instrument: II. Development and evaluation of the function component

BACKGROUND

Self-reported capability in physical functioning has long been considered an important focus of research for older persons. Current measures have been criticized, however, for conceptual confusion, lack of sensitivity to change, poor reproducibility, and inability to capture a wide range of upper and lower extremity functioning.

METHODS

Using Nagi's disablement model, we wrote physical functioning questionnaire items that assessed difficulty in 48 common daily tasks. We constructed the instrument using factor analysis and Rasch analytic techniques and evaluated its validity and test-retest reliability with 150 ethnically and racially diverse adults aged 60 years and older who had a range of functional limitations.

RESULTS

Our analyses resulted in a 32-item function component with three dimensions--upper extremity, basic lower extremity, and advanced lower extremity functions. Expected differences in summary scores of known-functional limitation groups support its validity. Test-retest stability over a 1- to 3-week period was extremely high (intraclass correlation coefficients =.91 to.98).

CONCLUSIONS

The Late-Life Function and Disability Instrument has potential to assess activity concepts related to upper and lower extremity functioning across a wide variety of daily physical tasks and individual levels of physical functioning.

Changes in depression and physical decline in older adults: a longitudinal perspective

BACKGROUND

The impact of chronicity and changes in depression on physical decline over time in older persons has not been elucidated.

METHODS

This prospective cohort study of 2121 community-dwelling persons aged 55-85 years uses two measurement occasions of depression (CES-D scale) over 3 years to distinguish persons with chronic, remitted, or emerging depression and persons who were never depressed. Physical function is assessed by self-reported physical ability as well as by observed performance on a short battery of tests.

RESULTS

After adjustment for baseline physical function, health status and sociodemographic factors, chronic depression was associated with significantly greater decline in self-reported physical ability over 3 years when compared to never depressed persons (odds ratio (OR)=2.83, 95% confidence interval (CI)=1.86-4. 30). In the oldest old, but not in the youngest old, chronic depression was also significantly predictive of greater decline in observed physical performance over 3 years (OR=2.22, 95% CI=1.43-3. 79). Comparable effects were found for older persons with emerging depression. Persons with remitted depression did not have greater decline in reported physical ability or observed performance than persons who were never depressed.

CONCLUSIONS

Our findings among community-dwelling older persons show that chronicity of depression has a large impact on physical decline over time. Since persons with remitted depression did not have greater physical decline than never depressed persons, these findings suggest that early recognition and treatment of depression in older persons could be protective for subsequent physical decline.

Problems of older adults living alone after hospitalization

OBJECTIVE

To describe functional deficits among older adults living alone and receiving home nursing following medical hospitalization, and the association of living alone with lack of functional improvement and nursing home utilization 1 month after hospitalization.

DESIGN

Secondary analysis of a prospective cohort study.

PARTICIPANTS

Consecutive sample of patients age 65 and over receiving home nursing following medical hospitalization. Patients were excluded for new diagnosis of myocardial infarction or stroke in the previous 2 months, diagnosis of dementia if living alone, or nonambulatory status. Of 613 patients invited to participate, 312 agreed.

MEASUREMENTS

One week after hospitalization, patients were assessed in the home for demographic information, medications, cognition, and self-report of prehospital and current mobility and function in activities of daily living (ADLs) and independent activities of daily living (IADLs). One month later, patients were asked about current function and nursing home utilization. The outcomes were lack of improvement in ADL function and nursing home utilization 1 month after hospitalization.

RESULTS

One hundred forty-one (45%) patients lived alone. After hospital discharge, 40% of those living alone and 62% of those living with others had at least 1 ADL dependency (P =.0001). Patients who were ADL-dependent and lived alone were 3.3 (95% confidence interval [95% CI], 1.4 to 7. 6) times less likely to improve in ADLs and 3.5 (95% CI, 1.0 to 11. 9) times more likely to be admitted to a nursing home in the month after hospitalization.

CONCLUSION

Patients who live alone and receive home nursing after hospitalization are less likely to improve in function and more likely to be admitted to a nursing home, compared with those who live with others. More intensive resources may be required to continue community living and maximize independence.

Prediction of survival for older hospitalized patients: the HELP survival model. Hospitalized Elderly Longitudinal Project

OBJECTIVE

To develop and validate a model estimating the survival time of hospitalized persons aged 80 years and older.

DESIGN

A prospective cohort study with mortality follow-up using the National Death Index.

SETTING

Four teaching hospitals in the US.

PARTICIPANTS

Hospitalized patients enrolled between January 1993 and November 1994 in the Hospitalized Elderly Longitudinal Project (HELP). Patients were excluded if their length of hospital stay was 48 hours or less or if admitted electively for planned surgery.

MEASUREMENTS

A log-normal model of survival time up to 711 days was developed with the following variables: patient demographics, disease category, nursing home residence, severity of physiologic imbalance, chart documentation of weight loss, current quality of life, exercise capacity, and functional status. We assessed whether model accuracy could be improved by including symptoms of depression or history of recent fall, serum albumin, physician's subjective estimate of prognosis, and physician and patient preferences for general approach to care.

RESULTS

A total of 1266 patients were enrolled over a 10-month period, (median age 84.9, 61% female, 68% with one or more dependency), and 505 (40%) died during an average follow-up of more than 2 years. Important prognostic factors included the Acute Physiology Score of APACHE III collected on the third hospital day, modified Glasgow coma score, major diagnosis (ICU categories together, congestive heart failure, cancer, orthopedic, and all other), age, activities of daily living, exercise capacity, chart documentation of weight loss, and global quality of life. The Somers' Dxy for a model including these factors was 0.48 (equivalent to a receiver-operator curve (ROC) area of 0.74, suggesting good discrimination). Bootstrap estimation indicated good model validation (corrected Dxy of 0.46, ROC of 0.73). A nomogram based on this log-normal model is presented to facilitate calculation of median survival time and 10th and 90th percentile of survival time. A count of geriatric syndromes or comorbidities did not add explanatory power to the model, nor did the hospital of patient recruitment, depression, or the patient preferences for general approach to care. The physician's perception of the patient's preferences and the physician's subjective estimate of the patient's prognosis improved the estimate of survival time significantly.

CONCLUSIONS

Accurate estimation of length of life for older hospitalized persons may be calculated using a limited amount of clinical information available from the medical chart plus a brief interview with the patient or surrogate. The accuracy of this model can be improved by including measures of the physician's perception of the patient's preferences for care and the physician's subjective estimate of prognosis.

Chair and bed rise performance in ADL-impaired congregate housing residents

OBJECTIVES

To examine the ability of activity of daily living (ADL)-impaired older adults to successfully rise, and, when successful, the time taken to rise, from a bed and chair under varying rise task demands.

SETTING

Seven congregate housing facilities

SUBJECTS

Congregate housing residents (n = 116, mean age 82) who admitted to requiring assistance (such as from a person, equipment, or device) in performing at least one of the following mobility-related ADLs: transferring, walking, bathing, and toileting.

METHODS

Subjects performed a series of bed and chair rise tasks where the rise task demand varied according to the head of bed (HOB) height, chair seat height, and use of hands. Bed rise tasks included supine to sit-to-edge, sit up in bed with hand use, and sit up in bed without hands, all performed from a bed where the HOB was adjusted to 0, 30, and 45 degrees elevations; roll to side-lying then rise (HOB 0 degrees); and supine to stand (HOB 0 degrees). Chair seat heights were adjusted according to the percent of the distance between the floor and the knee (% FK), and included rises (1) with hands and then without hands at 140, 120, 100, and 80% FK; (2) from a reclining (105 degrees at chair back) and tilting (seat tilted 10 degrees posteriorly) chair (100% FK); and (3) from a 80% FK seat height with a 4-inch cushion added, with and then without hands. Logistic regression for repeated measures was used to test for differences between tasks in the ability to rise. After log transformation of rise time, a linear effects model was used to compare rise time between tasks.

RESULTS

The median total number of tasks successfully completed was 18 (range, 3-21). Nearly all subjects were able to rise from positions where the starting surface was elevated as long as hand use was unlimited. With the HOB at 30 or 45 degrees essentially all subjects could complete supine to sit-to-edge and sit up with hands. Essentially all subjects could rise from a seat height at 140, 120, and 100% FK as long as hand use was allowed. A small group (8-10%) of subjects was dependent upon hand use to perform the least challenging tasks, such as 140% FK without hands chair rise and 45 degrees sit up without hands. This dependency upon hand use increased significantly as the demand of the task increased, that is, as the HOB or seat height was lowered. Approximately three-quarters of the sample could not rise from a flat (0 degrees HOB elevation) bed or low (80% FK) chair when hand use was not allowed. Similar trends were seen in rise performance time, that is, performance times tended to increase as the HOB or chair seat elevation declined and as hand use was limited. Total self-reported ADL disability, compared to the single ADL transferring item, was a stronger predictor of rise ability and timed rise performance, particularly for chair rise tasks.

CONCLUSIONS

Lowering HOB height and seat height increased bed and chair rise task difficulty, particularly when hand use was restricted. Restricting hand use in low HOB height or lowered seat height conditions may help to identify older adults with declining rise ability. Yet, many of those who could not rise under "without hands" conditions could rise under "with hands" conditions, suggesting that dependency on hand use may be a marker of progressive rise impairment but may not predict day-to-day natural milieu rise performance. Intertask differences in performance time may be statistically significant but are clinically small. Given the relationship between self-reported ADL disability and rise performance, impaired rise performance may be considered a marker for ADL disability. These bed and chair rise tasks can serve as outcomes for an intervention to improve bed and chair rise ability and might also be used in future studies to quantify improvements or declines in function over time, to refine physical therapy protocols, and to examine the effect of bed and chair design modifications on bed and chai

Detection of older people at increased risk of adverse health outcomes after an emergency visit: the ISAR screening tool

OBJECTIVES

To develop a self-report screening tool to identify older people in the emergency department (ED) of a hospital at increased risk of adverse health outcomes, including: death, admission to a nursing home or long-term hospitalization, or a clinically significant decrease in functional status.

DESIGN

Prospective (6-month) follow-up study of a cohort of ED patients aged 65 and older.

SETTING

The EDs of four acute-care hospitals in Montreal, Quebec, Canada.

PARTICIPANTS

Community-dwelling patients aged 65 and older who came to the EDs during the weekday shift over a 3-month recruitment period. Patients were excluded if they could not be interviewed either because of their medical condition or because of cognitive impairment and no other informant was available.

MEASUREMENTS

Measures ascertained at the ED visit included: 27 self-report screening questions on social, physical, and mental risk factors; medical history; use of hospital services, medications, and alcohol; and the Older American Resources and Services (OARS) activities of daily living (ADL) scale. At follow-up, the OARS scale was readministered by telephone, and other adverse health outcomes were ascertained.

RESULTS

Among 1673 patients who completed the follow-up measures, 488 (29.2%) had an adverse health outcome. Scale development and selection methods included logistic regression, receiver operating characteristic curves, and expert judgment. The proposed screening tool (ISAR) comprises six self-report questions on functional dependence (premorbid and acute change), recent hospitalization, impaired memory and vision, and polymedication. The tool performed well in the total cohort aged 65 and older, and in sub-groups defined by disposition (admitted or released from ED), language of questionnaire administration (French or English), information source (patient or other), and other characteristics.

CONCLUSIONS

The ISAR is a short self-report questionnaire that can quickly identify older patients in the ED at increased risk of several adverse health outcomes and those with current disability.