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Functional Outcomes of Acute Medical Illness and Hospitalization in Older Persons

Functional Outcomes of Acute Medical Illness and Hospitalization in Older Persons Abstract Background: Short-stay hospitalization in older patients is frequently associated with a loss of function, which can lead to a need for postdischarge assistance and longer-term institutionalization. Because little is known about this adverse outcome of hospitalization, this study was conducted to (1) determine the discharge and 3-month postdischarge functional outcomes for a large cohort of older persons hospitalized for medical illness, (2) determine the extent to which patients were able to recover to preadmission levels of functioning after hospital discharge, and (3) identify the patient factors associated with an increased risk of developing disability associated with acute illness and hospitalization. Methods: A total of 1279 community-dwelling patients, aged 70 years and older, hospitalized for acute medical illness were enrolled in this multicenter, prospective cohort study. Functional measurements obtained at discharge (Activities of Daily Living) and at 3 months after discharge (Activities of Daily Living and Instrumental Activities of Daily Living) were compared with a preadmission baseline level of functioning to document loss and recovery of functioning. Results: At discharge, 59% of the study population reported no change, 10% improved, and 31% declined in Activities of Daily Living when compared with the preadmission baseline. At the 3-month follow-up, 51% of the original study population, for whom postdischarge data were available (n=1206), were found to have died (11%) or to report new Activities of Daily Living and/or Instrumental Activities of Daily Living disabilities (40%) when compared with the preadmission baseline. Among survivors, 19% reported a new Activities of Daily Living and 40% reported a new Instrumental Activities of Daily Living disability at follow-up. The 3-month outcomes were the result of the loss of function during the index hospitalization, the failure of many patients to recover after discharge, and the development of new postdischarge disabilities. Patients at greatest risk of adverse functional outcomes at follow-up were older, had preadmission Instrumental Activities of Daily Living disabilities and lower mental status scores on admission, and had been rehospitalized. Conclusions: This study documents a high incidence of functional decline after hospitalization for acute medical illness. Although there are several potential explanations for these findings, this study suggests a need to reexamine current inpatient and postdischarge practices that might influence the functioning of older patients.(Arch Intern Med. 1996;156:645-652) References 1. Stewart AL, Greenfield S, Hays RD, et al. Functional status and well-being of patients with chronic conditions: results from the Medical Outcomes Study . JAMA. 1989;262:907-913.Crossref 2. Health and Public Policy Committee, American College of Physicians. Comprehensive functional assessment for elderly patients . Ann Intern Med. 1988; 109:70-72.Crossref 3. Fretwell MD. The frail elderly: creating standards of care . In: Spilder B, ed. Quality of Life Assessments in Clinical Trials . New York, NY: Raven Press Ltd; 1990:225-235. 4. Kahn KL, Keeler EB, Sherwood MJ, et al. Comparing outcomes of care before and after implementation of the DRG-based prospective payment system . JAMA. 1990;264:1984-1988.Crossref 5. Kahn KL, Rogers WH, Rubenstein LV, et al. Measuring quality of care with explicit process criteria before and after implementation of the DRG-based prospective payment system . JAMA. 1990;264:1969-1973.Crossref 6. Medicare Hospital Mortality Information, 1986 . Washington, DC: US Dept of Health and Human Services; 1987. Publication 01-002. 7. Dubois RW, Brook RH, Roger WH. Adjusted hospital death rates: a potential screen for quality of medical care . Am J Public Health. 1987;77:1162-1167.Crossref 8. Eisdorfer C, Maddox GL. A distinctive role for hospitals in caring for older adults: issues and options . In: Eisdorfer C, Maddox GL, eds. The Role of Hospitals in Geriatric Care . New York, NY: Springer Publishing Co; 1988:1-2. 9. McVey L, Becker PM, Saltz CC, Feussner J, Cohen H. Effects of a geriatric consult team on functional status in elderly hospitalized patients . Ann Intern Med. 1989;110:78-84Crossref 10. Hirsch CH, Sommers L, Olsen A, Mullen L, Winograd C. The natural history of functional morbidity in hospitalized older patients . J Am Geriatr Soc. 1990;38:1296-1303. 11. Lamont CT, Sampson S, Matthias R, Kane R. The outcome of hospitalization for acute illness in the elderly . J Am Geriatr Soc. 1983;31:282-288. 12. Warshaw GA, Moore JT, Friedman W, et al. Functional disability in the hospitalized elderly . JAMA. 1982;248:847-850.Crossref 13. Margitic SE, Inouye SK, Thomas JL, Cassel CK, Regenstreif DI, Kowal J. Hospital Outcomes Project for the Elderly (HOPE): rationale and design for prospective pooled analysis . J Am Geriatr Soc. 1993;41:258-267. 14. Folstein MF, Folstein SE, McHugh PR. 'Mini-mental state': a practical method for grading the cognitive state of patients for the clinician . J Psychiatr Res. 1975;12:189-198.Crossref 15. Inouye SK, Acampora D, Miller RL, Fulmer T, Hurst L, Cooney LM. The Yale Geriatric Care Program: a model of care to prevent functional decline in hospitalized elderly patients . J Am Geriatr Soc. 1993;38:1345-1352. 16. Palmer RM, Landefeld CS, Kresevec D, Kowal J. A medical unit for the acute care of the elderly . J Am Geriatr Soc. 1994;42:545-552. 17. Inouye SK, Wagner DR, Acompora D, Horwitz RI, Cooney LM, Tinetti ME. A controlled trial for a nursing centered intervention in hospitalized elderly medical patients: the Yale Geriatric Care Program . J Am Geriatr Soc. 1993;41:1353-1360. 18. Landefeld CD, Palmer RM, Kresevic DM, Fortinsky RH, Kowal J. A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients . N Engl J Med. 1995;332:1338-1344.Crossref 19. Rubenstein LZ, Schairer C, Wieland GD, Kane R. Systematic biases in functional status assessment of elderly adults: effects of different data sources . J Gerontol. 1984;39:686-691.Crossref 20. Sager MA, Dunham NC, Schwantes A, Mecum L, Halverson K, Harlowe D. Measurements of activities of daily living in hospitalized elderly: a comparison of self-report and performance-based measures . J Am Geriatr Soc. 1992;40:457-462. 21. Medicare and Medicaid Statistical Supplement. Health Care Financing Review 1992 Annual Supplement . Baltimore, Md: US Dept of Health and Human Services; 1992. 22. Buchner DM, Wagner EH. Preventing frail health . Clin Geriatr Med. 1992;8:1-17. 23. Guterman S, Eggers PW, Riley G, Greene F, Terrell S. The first three years of Medicare prospective payment: an overview. Health Care Financing Rev. 1988: 9:67-77. 24. Fitzgerald JF, Fagan LF, Tierney WM, Dittus R. Changing patterns of hip fracture care before and after implementation of the prospective payment system. JAMA. 1987;258:218-221.Crossref 25. Neu CR, Harrison SC. Post-hospital Care Before and After the Medicare Prospective Payment System . Santa Monica, Calif: RAND; 1988. 26. Creditor MC. Hazards of hospitalization of the elderly . Ann Intern Med. 1993; 118:219-223.Crossref 27. Hoenig HM, Rubenstein LZ. Hospital-associated deconditioning and dysfunction . J Am Geriatr Soc. 1991;39:220-221. 28. Harper CH, Lyles YM. Physiology and complications of bed rest . J Am Geriatr Soc. 1988;36:1047-1054. 29. Brennan TA, Leape L, Laerd N, et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study, I. N Engl J Med. 1991;324:370-376.Crossref 30. Steel K, Gertman P, Crescenzi B, Anderson J. latrogenic illness on a general medical service at a university hospital . N Engl J Med. 1981;304:638-642.Crossref 31. Becker PM, McVey LJ, Saltz CC, Fuessner J, Cohen H. Hospital-acquired complications in a randomized controlled clinical trial of a geriatric consultation team . JAMA. 1987;257:2313-2317.Crossref 32. Holt P, Winograd CH. Prospective payment and the utilization of physical therapy service in the hospitalized elderly . Am J Public Health. 1990;80:1491-1494.Crossref 33. Johnson J, Sager M, Hern G, Dunham N. Referral patterns to physical therapy in elderly hospitalized for acute medical illness . Phys Occup Ther Geriatr. 1994; 12( (2) ):1-12.Crossref 34. Boaz R. Improved versus deteriorated physical functioning among long-term disabled elderly . Med Care. 1994;32:588-602.Crossref 35. Seeman T, Charpentierr P, Berkman L, et al. Predicting changes in physical performance in a high functioning elderly cohort: MacArthur studies of successful aging . J Gerontol. 1994;49:3:M97-M108.Crossref 36. Mor V, Wilcox V, Rakowski W, Hiris J. Functional transitions among the elderly: patterns, predictors and related hospital use . Am J Public Health. 1994; 84:1274-1280.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

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References (34)

Publisher
American Medical Association
Copyright
Copyright © 1996 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1996.00440060067008
Publisher site
See Article on Publisher Site

Abstract

Abstract Background: Short-stay hospitalization in older patients is frequently associated with a loss of function, which can lead to a need for postdischarge assistance and longer-term institutionalization. Because little is known about this adverse outcome of hospitalization, this study was conducted to (1) determine the discharge and 3-month postdischarge functional outcomes for a large cohort of older persons hospitalized for medical illness, (2) determine the extent to which patients were able to recover to preadmission levels of functioning after hospital discharge, and (3) identify the patient factors associated with an increased risk of developing disability associated with acute illness and hospitalization. Methods: A total of 1279 community-dwelling patients, aged 70 years and older, hospitalized for acute medical illness were enrolled in this multicenter, prospective cohort study. Functional measurements obtained at discharge (Activities of Daily Living) and at 3 months after discharge (Activities of Daily Living and Instrumental Activities of Daily Living) were compared with a preadmission baseline level of functioning to document loss and recovery of functioning. Results: At discharge, 59% of the study population reported no change, 10% improved, and 31% declined in Activities of Daily Living when compared with the preadmission baseline. At the 3-month follow-up, 51% of the original study population, for whom postdischarge data were available (n=1206), were found to have died (11%) or to report new Activities of Daily Living and/or Instrumental Activities of Daily Living disabilities (40%) when compared with the preadmission baseline. Among survivors, 19% reported a new Activities of Daily Living and 40% reported a new Instrumental Activities of Daily Living disability at follow-up. The 3-month outcomes were the result of the loss of function during the index hospitalization, the failure of many patients to recover after discharge, and the development of new postdischarge disabilities. Patients at greatest risk of adverse functional outcomes at follow-up were older, had preadmission Instrumental Activities of Daily Living disabilities and lower mental status scores on admission, and had been rehospitalized. Conclusions: This study documents a high incidence of functional decline after hospitalization for acute medical illness. Although there are several potential explanations for these findings, this study suggests a need to reexamine current inpatient and postdischarge practices that might influence the functioning of older patients.(Arch Intern Med. 1996;156:645-652) References 1. Stewart AL, Greenfield S, Hays RD, et al. Functional status and well-being of patients with chronic conditions: results from the Medical Outcomes Study . JAMA. 1989;262:907-913.Crossref 2. Health and Public Policy Committee, American College of Physicians. Comprehensive functional assessment for elderly patients . Ann Intern Med. 1988; 109:70-72.Crossref 3. Fretwell MD. The frail elderly: creating standards of care . In: Spilder B, ed. Quality of Life Assessments in Clinical Trials . New York, NY: Raven Press Ltd; 1990:225-235. 4. Kahn KL, Keeler EB, Sherwood MJ, et al. Comparing outcomes of care before and after implementation of the DRG-based prospective payment system . JAMA. 1990;264:1984-1988.Crossref 5. Kahn KL, Rogers WH, Rubenstein LV, et al. Measuring quality of care with explicit process criteria before and after implementation of the DRG-based prospective payment system . JAMA. 1990;264:1969-1973.Crossref 6. Medicare Hospital Mortality Information, 1986 . Washington, DC: US Dept of Health and Human Services; 1987. Publication 01-002. 7. Dubois RW, Brook RH, Roger WH. Adjusted hospital death rates: a potential screen for quality of medical care . Am J Public Health. 1987;77:1162-1167.Crossref 8. Eisdorfer C, Maddox GL. A distinctive role for hospitals in caring for older adults: issues and options . In: Eisdorfer C, Maddox GL, eds. The Role of Hospitals in Geriatric Care . New York, NY: Springer Publishing Co; 1988:1-2. 9. McVey L, Becker PM, Saltz CC, Feussner J, Cohen H. Effects of a geriatric consult team on functional status in elderly hospitalized patients . Ann Intern Med. 1989;110:78-84Crossref 10. Hirsch CH, Sommers L, Olsen A, Mullen L, Winograd C. The natural history of functional morbidity in hospitalized older patients . J Am Geriatr Soc. 1990;38:1296-1303. 11. Lamont CT, Sampson S, Matthias R, Kane R. The outcome of hospitalization for acute illness in the elderly . J Am Geriatr Soc. 1983;31:282-288. 12. Warshaw GA, Moore JT, Friedman W, et al. Functional disability in the hospitalized elderly . JAMA. 1982;248:847-850.Crossref 13. Margitic SE, Inouye SK, Thomas JL, Cassel CK, Regenstreif DI, Kowal J. Hospital Outcomes Project for the Elderly (HOPE): rationale and design for prospective pooled analysis . J Am Geriatr Soc. 1993;41:258-267. 14. Folstein MF, Folstein SE, McHugh PR. 'Mini-mental state': a practical method for grading the cognitive state of patients for the clinician . J Psychiatr Res. 1975;12:189-198.Crossref 15. Inouye SK, Acampora D, Miller RL, Fulmer T, Hurst L, Cooney LM. The Yale Geriatric Care Program: a model of care to prevent functional decline in hospitalized elderly patients . J Am Geriatr Soc. 1993;38:1345-1352. 16. Palmer RM, Landefeld CS, Kresevec D, Kowal J. A medical unit for the acute care of the elderly . J Am Geriatr Soc. 1994;42:545-552. 17. Inouye SK, Wagner DR, Acompora D, Horwitz RI, Cooney LM, Tinetti ME. A controlled trial for a nursing centered intervention in hospitalized elderly medical patients: the Yale Geriatric Care Program . J Am Geriatr Soc. 1993;41:1353-1360. 18. Landefeld CD, Palmer RM, Kresevic DM, Fortinsky RH, Kowal J. A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients . N Engl J Med. 1995;332:1338-1344.Crossref 19. Rubenstein LZ, Schairer C, Wieland GD, Kane R. Systematic biases in functional status assessment of elderly adults: effects of different data sources . J Gerontol. 1984;39:686-691.Crossref 20. Sager MA, Dunham NC, Schwantes A, Mecum L, Halverson K, Harlowe D. Measurements of activities of daily living in hospitalized elderly: a comparison of self-report and performance-based measures . J Am Geriatr Soc. 1992;40:457-462. 21. Medicare and Medicaid Statistical Supplement. Health Care Financing Review 1992 Annual Supplement . Baltimore, Md: US Dept of Health and Human Services; 1992. 22. Buchner DM, Wagner EH. Preventing frail health . Clin Geriatr Med. 1992;8:1-17. 23. Guterman S, Eggers PW, Riley G, Greene F, Terrell S. The first three years of Medicare prospective payment: an overview. Health Care Financing Rev. 1988: 9:67-77. 24. Fitzgerald JF, Fagan LF, Tierney WM, Dittus R. Changing patterns of hip fracture care before and after implementation of the prospective payment system. JAMA. 1987;258:218-221.Crossref 25. Neu CR, Harrison SC. Post-hospital Care Before and After the Medicare Prospective Payment System . Santa Monica, Calif: RAND; 1988. 26. Creditor MC. Hazards of hospitalization of the elderly . Ann Intern Med. 1993; 118:219-223.Crossref 27. Hoenig HM, Rubenstein LZ. Hospital-associated deconditioning and dysfunction . J Am Geriatr Soc. 1991;39:220-221. 28. Harper CH, Lyles YM. Physiology and complications of bed rest . J Am Geriatr Soc. 1988;36:1047-1054. 29. Brennan TA, Leape L, Laerd N, et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study, I. N Engl J Med. 1991;324:370-376.Crossref 30. Steel K, Gertman P, Crescenzi B, Anderson J. latrogenic illness on a general medical service at a university hospital . N Engl J Med. 1981;304:638-642.Crossref 31. Becker PM, McVey LJ, Saltz CC, Fuessner J, Cohen H. Hospital-acquired complications in a randomized controlled clinical trial of a geriatric consultation team . JAMA. 1987;257:2313-2317.Crossref 32. Holt P, Winograd CH. Prospective payment and the utilization of physical therapy service in the hospitalized elderly . Am J Public Health. 1990;80:1491-1494.Crossref 33. Johnson J, Sager M, Hern G, Dunham N. Referral patterns to physical therapy in elderly hospitalized for acute medical illness . Phys Occup Ther Geriatr. 1994; 12( (2) ):1-12.Crossref 34. Boaz R. Improved versus deteriorated physical functioning among long-term disabled elderly . Med Care. 1994;32:588-602.Crossref 35. Seeman T, Charpentierr P, Berkman L, et al. Predicting changes in physical performance in a high functioning elderly cohort: MacArthur studies of successful aging . J Gerontol. 1994;49:3:M97-M108.Crossref 36. Mor V, Wilcox V, Rakowski W, Hiris J. Functional transitions among the elderly: patterns, predictors and related hospital use . Am J Public Health. 1994; 84:1274-1280.Crossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Mar 25, 1996

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