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a Division of Geriatrics, Saint Louis University Health Sciences Center, Missouri
David R. Thomas, Division of Geriatric Medicine, Saint Louis University School of Medicine, 1402 S. Grand Blvd., M238, St. Louis, MO 63104 E-mail: thomasdr{at}slu.edu.
DECLINE in functional status is a profound marker of morbidity and mortality. The death rate increases from 15% in individuals with only one instrumental activity of daily living (IADL) impairment to 21% in persons with one or two activity of daily living (ADL) impairments, to more than 37% in those with five or six ADL impairments (1). Disabled older adults are four to six times more likely to die than the nondisabled (2). Up to half of geriatric patients admitted to the hospital have either loss of or a diminished performance in at least one ADL. The decline in functional status occurs as early as the second day of the hospital admission (3)(4).
Decline in functional status during hospitalization is a major predictor of risk for subsequent acute illness (5) and of nursing home placement (6)(7). An estimated 59% of adults with five or more ADL impairments will be admitted to nursing homes (8). This suggests that in-hospital prevention of functional decline is an important intervention to prevent placement in a nursing home. As might be expected, older adults with substantial functional impairment in nursing homes show poorer function at the end of 6 months than those with higher function (9) and have a shorter life expectancy in the nursing home than institutionalized adults of the same age who are less impaired (10).
Baseline impairment in functional status itself also predicts further decline in functional status in older adults (1). For example, performance-based measures of lower body function have been found to predict subsequent disability (11). Lower body function itself is a significant predictor of mortality independent of ADL score (12). Impaired functional status also correlates with an increased risk for falls both in the community and in the nursing home (13)(14).
Frailty represents a marker for poor outcomes in older persons (15)(16). Frailty is often associated with subclinical cardiovascular disease (17). Loss of one or more IADLs is a marker for falls, fear of falling, and frailty (18). Dolan and colleagues (19) found that in hip fracture patients, delirium during hospitalization predicted decline in functional status over the next 2 years. Recently, Simonsick and colleagues (20) have developed a series of tests of higher level physical function that appears capable of identifying well-functioning persons in their 70s.
In this issue of the Journal, McCusker and colleagues (21) review the published literature addressing the predictors of functional decline in older hospitalized patients. The literature demonstrates considerable variation in methodology and definition of outcomes. In fact, only 27 of 1363 articles were extracted for the final review. The authors limited analysis to adverse outcomes defined as decline in ADLs (basic and instrumental), admission to a nursing home, or a composite of these adverse events including death. The differences in study design led to diverse conclusions. For example, older age was a predictor of an adverse outcome in 12 of 19 studies and not a predictor in seven other studies.
Several common features among the varied studies emerge. Delirium, residence in a nursing home, disease diagnosis, functional impairment at baseline, and longer hospital stay predict admission to a nursing home in most studies. Social factors, such as living alone, family choice, and lack of primary or informal support at home, were important predictors of nursing home admission. Interestingly, the degree of comorbidity, marital status, gender, and race were less predictive of nursing home admission.
Predictors of functional decline included worsening cognitive function, delirium, and worsening IADLs. To a lesser degree, age, living in a nursing home, medical diagnosis, gender, and baseline ADL score also predict functional decline. Among the factors that were not associated with functional decline were marital status, living alone, race, and comorbidity.
Confused? Various other predictive models developed from multivariate techniques show an even greater diversity of variables. Most of the models demonstrate only fair sensitivity and specificity, although some models clearly performed better than others. The variability in the published literature precluded a formal meta-analysis of the data.
A commonality of factors, as noted above, emerges as predictors of worsening functional decline. However, it appears that the decision to admit an older person to a nursing home is more dependent on social factors than on functional decline alone.
The importance of identifying predictors of functional decline and of nursing home admission at hospital admission lies in the fact that they may be amenable to intervention. An inpatient geriatric evaluation unit has demonstrated substantial improvement in functional status and a better survival rate at the 1-year follow-up compared with usual hospital care (22). Geriatric hospital units have improved ability to transfer, dress, and bathe compared to usual care (23). Improvement in ADLs and fewer discharges to a nursing home have been demonstrated in another study (24). In a large multicenter study, Cohen and colleagues (25) demonstrated that inpatient geriatric evaluation and management units reduced functional decline. Similar conclusions were drawn from a meta-analysis of 4959 subjects in 28 controlled trials of comprehensive geriatric assessment programs (26). In patients with delirium (one of the risk factors for institutionalization in McCusker and colleagues' study), an intervention aimed at educating nurses, mobilizing patients, assessing medications, and making environmental modifications improved functional status at discharge (27). Persons with congestive heart failure have poor function but do better functionally when they receive support from a geriatric team (28).
It would be useful to know at hospital admission which older adults were more likely to experience a decline in functional status. This would identify which older persons would require transfer to a nursing home, which older adults would need additional community resource planning, and which older adults were more likely to die. Assessing patients for these predictors at hospital admission is the key to intervention.
Received April 22, 2002
Accepted April 22, 2002
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