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Gait Speed in Hospitalized Older People: Comment on “Assessing Gait Speed in Acutely Ill Older Patients Admitted to an Acute Care for Elders Hospital Unit”

Gait Speed in Hospitalized Older People: Comment on “Assessing Gait Speed in Acutely Ill Older... Ostir et al1 provide compelling evidence that simple performance measures of function, like gait speed, are powerful indicators of important health care outcomes, even in acutely ill older persons. Much of the prior work on performance measures was based in community-dwelling older populations, in which the assumption that performance measures were reliable in medically stable people was central to assumptions about predictive ability. Ostir et al show that performance measures in acutely ill, medically unstable older adults retain their ability to provide important clinical information. Building on an ever-expanding evidence base, it is unequivocally clear that to understand and manage the health care needs, prognoses, and outcomes of older adults, we must incorporate indicators of function.2,3 Because most older adults have multiple interacting health conditions, it is simply insufficient to base services on only disease-specific guidelines and outcomes.4 In this era of high health care costs and financial constraints, we continue to struggle with the challenges of health care reform, especially in large government programs like Medicare and Medicaid. We are appropriately obligated to evaluate the effectiveness and efficiency of our services. On the basis of what we have learned from Ostir et al and other investigators, it is clear that the evidence base we need to evaluate services for older people, whether derived from clinical trials or health care system data, must account for function, including mobility. Thus, the continued failure to incorporate measures of function into clinical trials or into health information systems represents a serious barrier to informing and improving health care for older people. Functional status can be assessed using self-report, professional report, performance measures, or all 3 of these. While the first priority for practice and research with older people must be to incorporate functional status in any form, we should carefully consider the added value of performance measures of mobility. Mobility is a key component of disability. Performance measures of mobility are safe, very brief and reliable, and as suggested in the recent article of Ostir et al, may provide a unique perspective that is, at minimum, complementary and, at times, superior to reported function. Gait speed has been shown to predict multiple important outcomes, including hospitalization, disability, survival, and nursing home placement.5 More recently, gait speed, used as the sole indicator of frailty, predicted risk of functional decline with hospitalization.6 Gait speed also seems to provide important and unique prognostic information in other clinical situations, such as in predicting outcomes of cardiac surgery.7 Yes, there is a need for further work and more evidence. While Ostir et al demonstrate important effects, many issues of generalizability and clinical application remain. Will gait speed retain its predictive ability in older people hospitalized for conditions other than cardiopulmonary or digestive disorders, or in persons with cognitive impairment or depression? What is the role of social support as a modifier of mobility? Will repeated measures of gait speed help detect the common and serious problem of functional decline and mobility loss during hospitalization?8 While we already know a lot, how much more do we need to understand about the value of gait speed in other clinical settings, such as outpatient clinics, rehabilitation programs, home health services, and nursing homes? How should we interpret repeated measures of performance over time, especially over shorter periods when health is changing rapidly?9 If mobility is important, independent of overall functional status, do simple self-report or professional-report measures of mobility perform as well as physical performance measures?2 Nevertheless, we already know enough to begin to incorporate these measures into health care practice and research.10 It is time for clinicians, researchers, and policy makers to learn how to interpret measures of function and physical performance, to consider their potential contribution to each professional's mission and goals, and to act to incorporate them into their work. Back to top Article Information Correspondence: Dr Studenski, Division of Geriatric Medicine, Department of Internal Medicine, University of Pittsburgh School of Medicine, and VA Pittsburgh Healthcare System, 3471 Fifth Ave, Ste 500, Pittsburgh, PA 15090 (studenskiS@dom.pitt.edu). Financial Disclosure: None reported. Funding/Support: Dr Studenski is supported in part by the Pittsburgh Pepper Center, AG024827. References 1. Ostir GV, Berges I, Kuo Y-F, Goodwin JS, Ottenbacher KJ, Guralnik JM. Assessing gait speed in acutely ill older patients admitted to an acute care for the elders hospital unit. Arch Intern Med. 2012;172(4):ioi110018353-358Google ScholarCrossref 2. Covinsky KE, Pierluissi E, Johnston CB. Hospitalization-associated disability: “she was probably able to ambulate, but I’m not sure.” JAMA. 2011;306(16):1782-179322028354PubMedGoogle ScholarCrossref 3. Fried LP, Guralnik JM. Disability in older adults: evidence regarding significance, etiology, and risk. J Am Geriatr Soc. 1997;45(1):92-1008994496PubMedGoogle Scholar 4. Tinetti ME, Studenski SA. Comparative effectiveness research and patients with multiple chronic conditions. N Engl J Med. 2011;364(26):2478-248121696327PubMedGoogle ScholarCrossref 5. Abellan van Kan G, Rolland Y, Andrieu S, et al. Gait speed at usual pace as a predictor of adverse outcomes in community-dwelling older people an International Academy on Nutrition and Aging (IANA) Task Force. J Nutr Health Aging. 2009;13(10):881-88919924348PubMedGoogle ScholarCrossref 6. Gill TM, Allore HG, Gahbauer EA, Murphy TE. Change in disability after hospitalization or restricted activity in older persons. JAMA. 2010;304(17):1919-192821045098PubMedGoogle ScholarCrossref 7. Afilalo J, Eisenberg MJ, Morin JF, et al. Gait speed as an incremental predictor of mortality and major morbidity in elderly patients undergoing cardiac surgery. J Am Coll Cardiol. 2010;56(20):1668-167621050978PubMedGoogle ScholarCrossref 8. Brown CJ, Friedkin RJ, Inouye SK. Prevalence and outcomes of low mobility in hospitalized older patients. J Am Geriatr Soc. 2004;52(8):1263-127015271112PubMedGoogle ScholarCrossref 9. van Iersel MB, Munneke M, Esselink RA, Benraad CE, Olde Rikkert MG. Gait velocity and the Timed-Up-and-Go test were sensitive to changes in mobility in frail elderly patients. J Clin Epidemiol. 2008;61(2):186-19118177792PubMedGoogle ScholarCrossref 10. Studenski S. Bradypedia: is gait speed ready for clinical use? J Nutr Health Aging. 2009;13(10):878-88019924347PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Gait Speed in Hospitalized Older People: Comment on “Assessing Gait Speed in Acutely Ill Older Patients Admitted to an Acute Care for Elders Hospital Unit”

Archives of Internal Medicine , Volume 172 (4) – Feb 27, 2012

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Publisher
American Medical Association
Copyright
Copyright © 2012 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinternmed.2011.1951
Publisher site
See Article on Publisher Site

Abstract

Ostir et al1 provide compelling evidence that simple performance measures of function, like gait speed, are powerful indicators of important health care outcomes, even in acutely ill older persons. Much of the prior work on performance measures was based in community-dwelling older populations, in which the assumption that performance measures were reliable in medically stable people was central to assumptions about predictive ability. Ostir et al show that performance measures in acutely ill, medically unstable older adults retain their ability to provide important clinical information. Building on an ever-expanding evidence base, it is unequivocally clear that to understand and manage the health care needs, prognoses, and outcomes of older adults, we must incorporate indicators of function.2,3 Because most older adults have multiple interacting health conditions, it is simply insufficient to base services on only disease-specific guidelines and outcomes.4 In this era of high health care costs and financial constraints, we continue to struggle with the challenges of health care reform, especially in large government programs like Medicare and Medicaid. We are appropriately obligated to evaluate the effectiveness and efficiency of our services. On the basis of what we have learned from Ostir et al and other investigators, it is clear that the evidence base we need to evaluate services for older people, whether derived from clinical trials or health care system data, must account for function, including mobility. Thus, the continued failure to incorporate measures of function into clinical trials or into health information systems represents a serious barrier to informing and improving health care for older people. Functional status can be assessed using self-report, professional report, performance measures, or all 3 of these. While the first priority for practice and research with older people must be to incorporate functional status in any form, we should carefully consider the added value of performance measures of mobility. Mobility is a key component of disability. Performance measures of mobility are safe, very brief and reliable, and as suggested in the recent article of Ostir et al, may provide a unique perspective that is, at minimum, complementary and, at times, superior to reported function. Gait speed has been shown to predict multiple important outcomes, including hospitalization, disability, survival, and nursing home placement.5 More recently, gait speed, used as the sole indicator of frailty, predicted risk of functional decline with hospitalization.6 Gait speed also seems to provide important and unique prognostic information in other clinical situations, such as in predicting outcomes of cardiac surgery.7 Yes, there is a need for further work and more evidence. While Ostir et al demonstrate important effects, many issues of generalizability and clinical application remain. Will gait speed retain its predictive ability in older people hospitalized for conditions other than cardiopulmonary or digestive disorders, or in persons with cognitive impairment or depression? What is the role of social support as a modifier of mobility? Will repeated measures of gait speed help detect the common and serious problem of functional decline and mobility loss during hospitalization?8 While we already know a lot, how much more do we need to understand about the value of gait speed in other clinical settings, such as outpatient clinics, rehabilitation programs, home health services, and nursing homes? How should we interpret repeated measures of performance over time, especially over shorter periods when health is changing rapidly?9 If mobility is important, independent of overall functional status, do simple self-report or professional-report measures of mobility perform as well as physical performance measures?2 Nevertheless, we already know enough to begin to incorporate these measures into health care practice and research.10 It is time for clinicians, researchers, and policy makers to learn how to interpret measures of function and physical performance, to consider their potential contribution to each professional's mission and goals, and to act to incorporate them into their work. Back to top Article Information Correspondence: Dr Studenski, Division of Geriatric Medicine, Department of Internal Medicine, University of Pittsburgh School of Medicine, and VA Pittsburgh Healthcare System, 3471 Fifth Ave, Ste 500, Pittsburgh, PA 15090 (studenskiS@dom.pitt.edu). Financial Disclosure: None reported. Funding/Support: Dr Studenski is supported in part by the Pittsburgh Pepper Center, AG024827. References 1. Ostir GV, Berges I, Kuo Y-F, Goodwin JS, Ottenbacher KJ, Guralnik JM. Assessing gait speed in acutely ill older patients admitted to an acute care for the elders hospital unit. Arch Intern Med. 2012;172(4):ioi110018353-358Google ScholarCrossref 2. Covinsky KE, Pierluissi E, Johnston CB. Hospitalization-associated disability: “she was probably able to ambulate, but I’m not sure.” JAMA. 2011;306(16):1782-179322028354PubMedGoogle ScholarCrossref 3. Fried LP, Guralnik JM. Disability in older adults: evidence regarding significance, etiology, and risk. J Am Geriatr Soc. 1997;45(1):92-1008994496PubMedGoogle Scholar 4. Tinetti ME, Studenski SA. Comparative effectiveness research and patients with multiple chronic conditions. N Engl J Med. 2011;364(26):2478-248121696327PubMedGoogle ScholarCrossref 5. Abellan van Kan G, Rolland Y, Andrieu S, et al. Gait speed at usual pace as a predictor of adverse outcomes in community-dwelling older people an International Academy on Nutrition and Aging (IANA) Task Force. J Nutr Health Aging. 2009;13(10):881-88919924348PubMedGoogle ScholarCrossref 6. Gill TM, Allore HG, Gahbauer EA, Murphy TE. Change in disability after hospitalization or restricted activity in older persons. JAMA. 2010;304(17):1919-192821045098PubMedGoogle ScholarCrossref 7. Afilalo J, Eisenberg MJ, Morin JF, et al. Gait speed as an incremental predictor of mortality and major morbidity in elderly patients undergoing cardiac surgery. J Am Coll Cardiol. 2010;56(20):1668-167621050978PubMedGoogle ScholarCrossref 8. Brown CJ, Friedkin RJ, Inouye SK. Prevalence and outcomes of low mobility in hospitalized older patients. J Am Geriatr Soc. 2004;52(8):1263-127015271112PubMedGoogle ScholarCrossref 9. van Iersel MB, Munneke M, Esselink RA, Benraad CE, Olde Rikkert MG. Gait velocity and the Timed-Up-and-Go test were sensitive to changes in mobility in frail elderly patients. J Clin Epidemiol. 2008;61(2):186-19118177792PubMedGoogle ScholarCrossref 10. Studenski S. Bradypedia: is gait speed ready for clinical use? J Nutr Health Aging. 2009;13(10):878-88019924347PubMedGoogle ScholarCrossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Feb 27, 2012

Keywords: hospital units,acute care,older adult,walking speed

References