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Hospitalization and Development of Dependence in Activities of Daily Living in a Cohort of Disabled Older Women: The Women's Health and Aging Study I

¹ Division of Geriatric Medicine and Gerontology, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
² Center on Aging and Health
³ Department of Epidemiology, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, Maryland.
⁴ National Institute on Aging, Bethesda, Maryland.

Address correspondence to Cynthia Boyd, MD, MPH, Center on Aging and Health, 2024 E. Monument St., Suite 2-700, Baltimore, MD 21205. E-mail: cyboyd{at}jhmi.edu

	Abstract

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Background. Changes in self-reported function in older adults are known to occur in the 2 weeks prior to, during, and in the first few months after hospitalization. The long-term outcome of hospitalization on functional status in disabled older adults is not known. The objective of this study was to determine whether hospitalization predicts long-term Activities of Daily Living (ADL) dependence in previously ADL independent, although disabled, older women.

Methods. The Women's Health and Aging Study I is a population-based, prospective cohort study of disabled, community-dwelling women 65 years old. We evaluated participants who were independent in ADLs at baseline and excluded women with incident stroke, lower extremity joint surgery, amputation, or hip fracture. We examined the association between self-reported incident hospitalization at three consecutive 6-month intervals and incident dependence in at least one ADL at 18 months (n = 595).

Results. Of 595 women evaluated, 32% had at least one hospitalization. Women who were hospitalized were more likely to become dependent in ADLs than were women who were not hospitalized (17% vs 8%, p =.001). In a multivariate model, hospitalization was independently predictive of development of ADL dependence that persisted at 18 months after baseline (odds ratio [OR], 3.2; 95% confidence interval [CI], 1.7–5.8), adjusting for age, race, education, baseline walking speed, difficulty with ADLs, self-reported health status, depressive symptoms, cognitive status, and presence of congestive heart failure, diabetes, or pulmonary disease. Increasing numbers of 6-month intervals with hospitalizations were independently predictive of higher risk in an adjusted model: one (OR, 2.3; 95% CI, 1.1–4.6), two (OR, 5.8; 95% CI, 2.4–14.4), and three (OR, 12.5; 95% CI, 2.7–57.6).

Conclusions. These results suggest that hospitalization has an independent and dose-response effect on loss of ADL independence in disabled older women over an 18-month period.

It is not known whether short-term functional declines after hospitalization persist beyond 3 months or whether the effect of hospitalization for acute illness is independent of the underlying health status. In addition, it has been proposed that recurrent episodes of illness lead to stepwise decline in function in older adults due to incomplete recovery of function after each episode (6). This hypothesis is clinically plausible but has not yet been formally evaluated. Hospitalizations could provide markers of more severe episodes of illness and thus could serve as a basis for evaluating this hypothesis of stepwise decline in function. If hospitalization for acute illness contributes to long-term functional decline beyond underlying health status, then this contribution would argue for increased attention to care delivery methods and how they could less adversely affect vulnerable older adults.

To assess the long-term functional implications of hospitalization in older adults, we studied a cohort of community-dwelling, moderately disabled older women who were independent in ADLs at baseline, to determine prospectively: (a) whether hospitalization is independently predictive of incident ADL dependence over an 18-month follow-up, and (b) if there is a dose-response association between number of hospitalizations and likelihood of incident ADL dependence.

	METHODS

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The Women's Health and Aging Study I (WHAS I) is a population-based, prospective, observational study of 1002 moderately to severely disabled community-dwelling older women, which has been described previously (7–9). The WHAS I cohort was derived from an age-stratified random sample of 32,538 women aged 65 years in Eastern Baltimore City and County identified with 1992 Medicare data. Of those sampled (N = 6521), 5316 were alive and living at home, and 4137 participated in at-home screening. Thirty-four percent of screened women were eligible for enrollment using the following criteria: (1) difficulty or dependence with tasks in at least two of four functional domains: (a) mobility, (b) upper extremity function, (c) higher functioning tasks, and (d) self-care tasks; and (2) Mini-Mental State Examination (MMSE) score 18 (10). Seventy-one percent of eligible women agreed to participate, resulting in 1002 participants. Participation rates did not vary by disability severity or self-reported health status.

Participants were examined at home every 6 months. At baseline, standardized data were collected on demographic factors, prior hospitalizations, self-reported health status, depressive symptoms as measured by the Geriatric Depression Scale (GDS) (11), and cognitive function as measured by the MMSE (10). Self-reported physical function was assessed in terms of difficulty and dependence in tasks in each of the four domains and physical performance measures, which included a standardized, 4-meter measured walk at usual pace. Each participant walked 4 meters, and a stopwatch measured their time for the first meter and the whole 4 meters. Validation of 17 major chronic conditions for all participants was performed at baseline using state-of-the-art algorithms (9) to define disease presence based on data collected from standardized patient interviews, standardized examinations by a trained nurse, medication reviews, laboratory studies, radiographs of hip and knee, physician questionnaires, and medical record review, with adjudication by trained clinicians.

At each 6-month follow-up, current self-reported assessment of difficulty and dependence with tasks was ascertained. Hospitalizations reported at each 6-month evaluation were used to characterize hospitalization status during the prior 6-month interval. ADL dependence at baseline and at 18-months follow-up was defined as a positive response to any of five questions, with the format "Do you usually receive help from another person in ‘toileting’?" (bathing, transferring, eating, dressing). Women who were ADL-independent at baseline were considered at risk of ADL dependence, and were included in these analyses.

Population characteristics of the study sample were described and stratified by hospitalization status. We first determined the frequency of transitions from independence to dependence in ADLs for each 6-month interval, stratified by whether the women had been hospitalized during that interval. The association of categorical variables and incident ADL dependence was assessed using contingency tables and the chi-square test. Multiple logistic regression was used to evaluate whether hospitalization was independently associated with incident ADL dependence, adjusting for potential independent predictors and confounders at baseline, including: age, race, education, validated chronic medical conditions, self-reported health status, depressive symptoms, cognitive status, and baseline functional status as assessed by the presence of difficulty (without dependence) with ADLs at baseline and usual walking speed (1/time to walk 1 meter). Variables in the model were selected based on review of the literature (12–21) and on results from bivariate analyses, in which 17 specific chronic diseases and number of chronic diseases were examined individually. Interactions between hospitalization and other hypothesized variables were examined. The presence of a dose-response relationship between the number of 6-month intervals during which at least one hospitalization was reported (no, one, two, or three) and frequency of ADL dependence at 18 months was assessed. To further verify whether there was a long-term association between hospitalization and disability, an analysis was conducted on the subset of women who had complete information on hospitalization at 18 months but had not been hospitalized during the final 6-month interval.

	RESULTS

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In these analyses, we sought to determine whether incident hospitalization is associated with development of ADL dependence among disabled women who were ADL-independent at baseline. Of 784 disabled women who were ADL-independent at baseline, 6.5% (n = 51) died by 18 months of follow-up and were excluded, as were 44 women who had an incident hospitalization for conditions likely to overwhelmingly cause disability in the short run, i.e., lower extremity joint surgery, amputation, stroke, or hip fracture. We excluded women who had missing data on hospitalization and/or ADLs at 18 months of follow-up (n = 94); this exclusion resulted in 595 women who were independent in ADLs at baseline and were alive and examined at 18 months. Age ranged from 65 to 100 years, and 28% were African-American (Table 1). Seventeen percent of participants had at least four chronic diseases. This population was moderately disabled, with 61% of participants, all ADL-independent at baseline, reporting baseline difficulty with at least one ADL. Thirty-two percent of women had at least one hospitalization in the 18 months of follow-up. Twenty-three percent had one interval with hospitalization, 7% had two intervals, and 2% had three intervals. African-American women were significantly more likely to be hospitalized, as were people with a baseline diagnosis of congestive heart failure or 0–8 years of education.

View larger version (18K): [in this window] [in a new window]   Figure 1. Percentage of nondependent women who became activities of daily living (ADL) dependent over each 6-month interval, according to hospitalization during that interval. All ADL-independent women at the beginning of each interval were included in the analysis; thus, n varies from interval to interval

Finally, to examine whether there was a dose-response effect of the number of 6-month intervals in which there was a hospitalization (no, one, two, or three intervals possible) on incident ADL dependence, we compared those women with no known hospitalizations to the women with one, two, or three intervals with hospitalization. Eight percent of those with no reported hospitalizations developed ADL dependence, versus 12.4% of those with only one interval, 27.9% of those with two intervals, and 30.0% of those with all three intervals with a known hospitalization (p <.001) (Table 2). In a multiple logistic regression model adjusting for the same confounders as above, risk of incident ADL dependence increased in a step-wise manner with an increasing number of intervals in which there was a hospitalization: OR = 2.3 (95% CI, 1.1–4.6) for one interval, OR = 5.8 (95% CI, 2.4–14.4) for two intervals, OR = 12.5 (95% CI, 2.7–57.6) for three intervals in which hospitalized, compared with no hospitalizations (Table 3). There were no significant multiplicative interactions between hospitalizations and other predictors.

	DISCUSSION

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In this study of community-dwelling, moderately disabled older women, hospitalization for acute illness was an independent predictor of functional decline persisting at least 6 months after hospitalization, controlling for other established predictors of disability progression. These results extend prior findings indicating that hospitalization for acute illness is associated with short-term functional decline among hospitalized older adults (3–5). There were significantly higher rates of ADL dependence at 18 months of follow-up in those women who were hospitalized one or more times during the follow-up, compared with women who were not hospitalized. In this prospective, population-based cohort of disabled, older, community-dwelling women, the data support the hypothesis that the experience of hospitalization for acute illness independently contributes to functional decline over and above underlying health status and sociodemographic factors. From a clinical, public health and public policy perspective, understanding both the role that hospitalization plays in the progression of disability and who is at risk is crucial in setting goals for improving both individual patient care and systems of care for the prevention of loss of independence.

We also sought in this analysis to provide formal evaluation of Buchner and Wagner's model (6) that the development of disability or frailty occurs in a stepwise fashion, with declines and then incomplete recovery after an acute illness. In this case, we used hospitalization as the marker for such acute illnesses. We found that the number of intervals with hospitalizations had a dose-response effect on the odds of developing ADL dependence, indicating that repeated hospitalizations conferred cumulative risk. This could potentially result from heightened vulnerability or incomplete functional recovery after each hospitalization.

With rare exceptions (18,22,23), prior studies examining the effect of hospitalization itself were not population-based, and evaluated only those older adults who were hospitalized (3–5,24–26). In this study we were able to examine a representative, community-based sample of moderately disabled older women, compare prospectively collected data on women who were and were not hospitalized subsequently, and adjust for other established predictors of disability, so as to determine the strength of the independent association between hospitalization for acute illness and progression of disability in a community-dwelling population.

Our study examined the independent association between hospitalization for acute illness and progression of disability, controlling for underlying risk factors such as race (13), depressive symptoms (14–16), baseline cognitive status (17), education (18), presence of chronic conditions (18–21), and age (19). In prior studies of hospitalized patients, physical performance before hospitalization, as measured by the lack of use of mobility assistive device (27), and after hospitalization, as measured by the timed "get up and go" test (28), affected likelihood of ADL dependence. Recent evidence suggests that performance measures (17,29) and milder forms of disability, such as difficulty without dependence (30) and preclinical mobility disability (31), also predict subsequent disability in population-based studies. Building on this prior work, we have shown that, when controlling for both physical performance and ADL difficulty, the association between hospitalization for acute illness and ADL dependence remains strong and independent, while slow baseline measured walking speed is also an independent predictor of incident ADL dependence.

In a study by Gill and colleagues looking at hospitalization outcomes in the Project Safety and Established Populations for Epidemiologic Study of the Elderly cohorts of community-dwelling adults aged 72 or older, baseline vulnerability (defined using gait speed, MMSE, and age) and the magnitude of precipitating events (severity of illness and hospitalization) were each independently associated with developing functional dependence with ADLs or admission to a skilled nursing facility up to 1 year after the baseline interview (23). This work suggests that both underlying vulnerability and severity of precipitating events are important to understanding stepwise functional decline in a population with a broader range of function. In the WHAS I subset of moderately disabled older women, we have confirmed their findings that age and slow walking speed are major predictors of baseline vulnerability, even among an expanded number of variables. Additionally, we have shown similar effects over a longer (18-month period), as compared to a 12-month period, and shown evidence of cumulative risk with recurrent hospitalization. In addition, we have shown that the effect is not merely a result of recent hospitalizations by using separate analyses excluding women with a hospitalization in the 6 months prior to follow-up.

The strengths of this study are that it used a population-based sample; targeted a vulnerable population of older women living in the community; included almost one third African-Americans; and had a minimal selection bias based on disability status, as assessments occurred in the home. The women in our sample had at least moderate disability at baseline, a known risk factor for future hospitalization and progression of disability. In this study, we were able to prospectively characterize participants' health and functional status prior to hospitalization; this has not been possible in studies which began their follow-up of patients when they were admitted to the hospital, and had to use retrospectively collected self-report data about their function 2 weeks prior to admission as baseline (5,25,26,32).

Our study is limited by the necessity, analytically, of classifying self-reported hospitalizations within 6-month intervals. Using self-report of hospitalization over a 6-month period in an older, disabled population is reasonable based on current evidence (33,34), although hospitalization may be underreported (35). We also examined only disabled older women; although this limits generalizability, older women have been shown to have higher disability rates than men in virtually all studies of disability prevalence and thus represent a group at high risk for further decline (36). Finally, further work is needed to discriminate illness effects from hospitalization effects. In this study, we could not differentiate between the hospitalization experience and the nature or severity of the illness itself that precipitated hospitalization, although we could take into account preexisting disease and other established predictors of disability. However, this work suggests that being hospitalized for acute illness contributes significantly and independently to the onset of functional dependence among older, community-dwelling disabled women beyond underlying health and sociodemographic status.

It is well recognized that older, functionally impaired adults have the highest hospitalization rates (30,37–39). The Medicare population accounted for more than 36% of all hospital stays and 49% of all inpatient days of hospital care in 1997 (40). Understanding the implications of these hospitalization events from a population-based, long-term perspective is of great clinical and public health importance, given the large number of older patients hospitalized and the significance of disability progression to older people. Functional decline associated with hospitalization is likely to be a joint result of the illness itself and unintended, but adverse, consequences of hospital care. Mechanisms for the latter could include immobilization, unfamiliarity of the environment, disruption of usual eating and sleeping patterns, and/or adverse consequences of procedures (2). Several innovative interdisciplinary care models have improved short-term functional outcomes and rates of delirium, such as Acute Care of the Elderly units, the Elder Life Program, and Geriatric Evaluation and Management units (41–44). Other methods such as home hospital, rehabilitative services, and nursing managed discharge are exciting possibilities for improving the long-term outcomes for older adults after hospitalization (45–47). Given the long-term functional outcomes of hospitalization demonstrated here, these innovative systems of care deserve attention and further research, with additional focus on the prevention of hospitalization and rehabilitation, to maximally benefit health outcomes for at-risk older adults (48).

This work indicates that moderately disabled older women are at high risk for further, and long-term, functional decline associated with hospitalization for acute illness, with risk increasing with recurrent hospitalization. The implications of this study are that targeting interventions during and after hospitalization to improve the long-term outcomes with which it is associated would likely benefit the at-risk older population. Efforts to both prevent functional decline and improve rates of functional recovery after hospitalization would have a substantial health impact on the aging population.

	Acknowledgments

 
This work was performed while Dr. Boyd was a Hartford/AFAR Academic Geriatrics Fellow and postdoctoral fellow under training grant NIH-T32-AG00120. The Women's Health and Aging Study I was funded by National Institute on Aging contracts NO-1AG-1-2112 and 1 RO1 AG 19905-1.

This study was approved by the Johns Hopkins University School of Medicine IRB, the Joint Committee on Clinical Investigation, RPN NO: 90-06-11-08.

	Footnotes

 
Decision Editor: John E. Morley, MB, BCh

Received March 25, 2004

Accepted April 13, 2004

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Boyd, C. M. Articles by Fried, L. P. Search for Related Content PubMed PubMed Citation Articles by Boyd, C. M. Articles by Fried, L. P.