Richard H. Fortinsky

Loss of Independence in Activities of Daily Living in Older Adults Hospitalized with Medical Illnesses: Increased Vulnerability with Age

OBJECTIVES: To describe the changes in activities of daily living (ADL) function occurring before and after hospital admission in older people hospitalized with medical illness and to assess the effect of age on loss of ADL function.

A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients.

BACKGROUND Older persons who re hospitalized for acute illnesses often lose their independence and are discharged to institutions for long-term care. METHODS We studied 651 patients 70 years of age or older who were admitted for general medical care at a teaching hospital; these patients were randomly assigned to receive usual care or to be cared for in a special unit designed to help older persons maintain or achieve independence in self-care activities. The key elements of this program were a specially prepared environment (with, for example, uncluttered hallways, large clocks and calendars, and handrails); patient-centered care emphasizing independence, including specific protocols for prevention of disability and for rehabilitation; discharge planning with the goal of returning the patient to his or her home; and intensive review of medical care to minimize the adverse effects of procedures and medications. The main outcome we measured ws the change from admission to discharge in the number of five basic activities of daily living (bathing, getting dressed, using the toilet, moving from a bed to a chair, and eating) that the patient could perform independently. RESULTS Twenty-four patients in each group died in the hospital. At the time of discharge, 65 (21 percent) of the 303 surviving patients in the intervention group were classified as much better in terms of their ability to perform basic activities of daily living, 39 (13 percent) as better, 151 (50 percent) as unchanged, 22 (7 percent) as worse, and 26 (9 percent) as much worse. In the usual care group, 40 (13 percent) of the 300 surviving patients were classified as much better, 33 (11 percent) as better, 163 (54 percent) as unchanged, 39 (13 percent) as worse, and 25 (8 percent) as much worse (P = 0.009). The difference between the groups remained significant (P = 0.04) in a multivariable model in which we controlled for potentially confounding base-line characteristics of the patients. Lengths of stay and hospital charges were similar in the two groups. Fewer patients assigned to the intervention group were discharged to long-term care institutions (43 patients [14 percent], as compared with 67 patients [22 percent] in the usual-care group; P = 0.01). Among the 493 patients discharged to private homes, similar proportions (about 10 percent) in the two groups were admitted to long-term care institutions during the three months after discharge. CONCLUSIONS Specific changes in the provision of acute hospital care can improve the ability of a heterogeneous group of acutely ill older patients to perform basic activities of daily living at the time of discharge from the hospital and can reduce the frequency of discharge to institutions for long-term care.

Effects of a Multicomponent Intervention on Functional Outcomes and Process of Care in Hospitalized Older Patients: A Randomized Controlled Trial of Acute Care for Elders (ACE) in a Community Hospital

BACKGROUND: Older persons frequently experience a decline in function following an acute medical illness and hospitalization.

Recovery of Activities of Daily Living in Older Adults After Hospitalization for Acute Medical Illness

OBJECTIVES: To compare functional outcomes in the year after discharge for older adults discharged from the hospital after an acute medical illness with a new or additional disability in their basic self‐care activities of daily living (ADL) (compared with preadmission baseline 2 weeks before admission) with those of older adults discharged with baseline ADL function and identify predictors of failure to recover to baseline function 1 year after discharge.

Depressive Symptoms and 3-Year Mortality in Older Hospitalized Medical Patients

Hospitalization is associated with a long-term increased risk for death, especially in older persons (1-4). Although the mediators for this increased risk have not been fully elucidated, depression may play an important role. Because depression is common in hospitalized older patients, an association between depression and mortality in this population would be of significant clinical importance (5-13). The hypothesis that depression may be a mediator of death in hospitalized patients is supported by studies demonstrating that depressive symptoms are associated with increased mortality in community-dwelling patients and in highly selected groups of hospitalized older patients, such as those with acute myocardial infarction (14-18). These studies have often been limited by inadequate accounting for the complex interrelations between depressive symptoms and other predictors of death, such as acute physiologic impairment, chronic comorbid illness, functional impairment, and cognitive impairment. Because depressive symptoms are clearly correlated with and may partly be the result of these other factors (5, 19-20), improving our understanding of the relation between depression and death requires use of standardized methods to measure and adjust for confounders. We tested the hypothesis that depressive symptoms are associated with long-term mortality in hospitalized older patients. We demonstrated previously that depressive symptoms are strongly associated with adverse health status outcomes in hospitalized medical patients through 90 days after admission (21). However, our initial study found no association between depressive symptoms and mortality during the first 90 days after admission (21). In this report, we extend mortality follow-up to 3 years by merging our data with a national mortality database. Furthermore, we adjusted for standard measures of physiologic impairment, comorbid illness, and functional impairment at hospital admission to control for the possibility that higher levels of these confounders in patients with more depressive symptoms affect the association between depressive symptoms and death. Methods Patients Patients were drawn from serial, prospective longitudinal studies of functional change in older hospitalized patients on the general medical service of University Hospitals of Cleveland. The inclusion and exclusion criteria for these studies are described elsewhere (3, 21, 22). The first study enrolled 206 patients 75 years of age or older who were admitted between March 1990 and July 1990. The second study, a controlled trial of an intervention to improve functional outcomes, enrolled 651 patients 70 years of age or older who were admitted between November 1990 and March 1992. The first study, which was a pilot study for the second study, enrolled consecutive patients. The second study randomly assigned patients to an intervention designed to improve functional outcomes in older persons or to usual care (22). In each study, patients admitted to the intensive care unit, telemetry service, or oncology service were excluded. Data collection procedures in both studies were almost identical. Other than a slightly higher mean patient age in the first study cohort, the demographic, clinical, and functional characteristics of patients in the first study, the control group of the second study, and the intervention group of the second study were similar. Additional analyses that adjusted for whether patients were in the first study cohort or the control group compared with the intervention group of the second study cohort yielded results that were almost identical to the results reported here. Of 857 older patients enrolled in the two studies, 284 were excluded from the current study because they were too ill or confused to be interviewed about depressive symptoms at the time of admission (n=164), were admitted from nursing homes (n=38), were not available for interview (n=37), declined interview (n=27), or died before being approached (n=18). We excluded patients admitted from nursing homes because interview data were less consistently obtained from these patients. Thus, the analytic sample for this study comprised 573 patients. Assessment of Depressive Symptoms Within 48 hours of admission, patients were interviewed by using the 15-item Geriatric Depression Scale to assess depressive symptoms over the past week (23, 24). The Geriatric Depression Scale is well suited for use in acutely ill older persons because it focuses on symptoms of depression that are less likely to be directly influenced by somatic illness. Examples of items on this scale include feeling bored, dropping activities and interests, feeling helpless, feeling worthless, feeling that life is empty, feeling that others are better off, preferring to stay at home instead of doing new things, and feeling hopeless. We divided patients into those reporting five or fewer symptoms and those reporting six or more symptoms; these are commonly recommended cutoffs on the 15-item Geriatric Depression Scale (24-26). Measurement of Mortality We determined mortality and date of death during the 3 years after hospitalization by merging our files with the National Death Index, a database of all deaths in the United States generated from state death certificates. Its sensitivity and specificity have been reported to be 98% and 100%, respectively (27). Measurement of Potential Confounders Shortly after admission, we surveyed each patients primary nurse about the patients independence in six activities of daily living (dressing, bathing, grooming, toileting, transferring, and eating) based on the scale of Katz (28). Within 48 hours of admission, we administered to patients the first 21 items of the 30-item Folstein Mini-Mental State Examination (29). To minimize respondent burden, we used only the first 21 items. Scores on the 21-item instrument have previously been shown to correlate highly (r=0.9) with scores on the 30-item instrument and to have construct validity on the basis of their strong association with functional outcomes (30). Data gathered from medical records included the reason for admission, the components of the Acute Physiology and Chronic Health Evaluation (APACHE) II score (31), and the components of the weighted Charlson comorbidity index of illness (32). The APACHE II score is a commonly used measure of physiologic severity, and the Charlson score is often used as a measure of the burden of comorbid illness. Statistical Analysis For our primary set of analyses, we compared patients who had six or more depressive symptoms (depressed patients) with patients who had five or fewer symptoms (nondepressed patients). We used the chi-square test or t-test to compare the characteristics of patients in each category at hospital admission. Survival curves describing mortality in the 3 years after hospitalization in each group were prepared by using the method of Kaplan and Meier. We used Cox regression to determine whether depressive symptoms were independently associated with mortality over 3 years. In the first model, we measured the unadjusted association between depressive symptoms and mortality. In the next four models, we determined the association between depressive symptoms and mortality after controlling for APACHE II scores, Charlson comorbidity index scores, dependence in activities of daily living, or cognitive function. In the sixth model, we controlled for all of these potential confounders as well as age, sex, ethnicity, and whether the patient lived alone. We did two secondary analyses. First, we modeled depression scores as the number of depressive symptoms on admission. We also determined the hazard ratio associated with multiple cut-points on the Geriatric Depression Scale. Results The mean age of the 573 patients was 79.9 years; 67.8% of patients were women and 39.4% were African-American. About half were independent in all activities of daily living at hospital admission. Table 1 lists the 10 most common reasons for hospital admission, classified by using the method of Charlson (33). The mean number of depressive symptoms at hospital admission was 4.5, and 34% of patients reported six or more symptoms. At admission, patients with six or more depressive symptoms had higher comorbidity scores, were more likely to have congestive heart failure or chronic obstructive pulmonary disease, had lower cognitive function scores, and were dependent in more activities of daily living (Table 2). Three years after admission (Figure), the mortality rate was higher among patients with six or more depressive symptoms than among patients with five or fewer depressive symptoms (56% compared with 40%; P<0.001). Of the 376 patients with five or fewer depressive symptoms at admission, 78 (21%) died during the first year of follow-up, 121 (32%) died during the first 2 years, and 151 (40%) died during the 3 years. Of the 197 patients with six or more depressive symptoms on admission, 58 (29%) died in the first year, 88 (45%) died during the first 2 years, and 110 (56%) died during the 3 years. The unadjusted hazard ratio over 3 years of follow-up for patients with six or more depressive symptoms was 1.56 (95% CI, 1.22 to 2.00). Patients with six or more depressive symptoms were also slightly more likely than patients with five or fewer symptoms to be discharged to a nursing home (8.3% compared with 4.9%; P=0.11). Table 1. Most Common Reasons for Hospital Admission (n=573) Table 2. Characteristics of Patients at Hospital Admission Figure. Mortality over 3 years (1095 days) in patients who had six or more depressive symptoms compared with patients who had five or fewer symptoms. Although adjustment for physiologic severity, comorbid illness, dependence in activities of daily living, and cognitive function each reduced the strength of the association between depressive symptoms and mortality, in each case this association remained statistically

Fall-risk assessment and management in clinical practice: Views from healthcare providers

Objectives: To determine the extent to which healthcare providers reportedly address evidence‐based fall risk factors in older patients after exposure to an educational intervention and to determine barriers reportedly encountered when these healthcare providers intervene with or refer older patients with identified fall‐risk factors.

How Well Are Community-Living Women Treated for Osteoporosis after Hip Fracture?

To examine whether women with recent hip fracture are receiving adequate treatment for osteoporosis. To examine patient and physician characteristics associated with adequate treatment for osteoporosis.

The Relation Between Health Status Changes and Patient Satisfaction in Older Hospitalized Medical Patients

OBJECTIVE: To examine the relation between two patient outcome measures that can be used to assess the quality of hospital care: changes in health status between admission and discharge, and patient satisfaction.DESIGN: Prospective cohort study.SETTING AND PATIENTS: Subjects were 445 older medical patients (aged ≥70 years) hospitalized on the medical service of a teaching hospital.MEASUREMENTS AND MAIN RESULTS: We interviewed patients at admission and discharge to obtain two measures of health status: global health and independence in five activities of daily living (ADLs). At discharge, we also administered a 5-item patient satisfaction questionnaire. We assessed the relation between changes in health status and patient satisfaction in two sets of analyses, that controlled for either admission or discharge health status. When controlling for admission health status, changes in health status between admission and discharge were positively associated with patient satisfaction (p values ranging from .01 to .08). However, when controlling for discharge health status, changes in health status were no longer associated with patient satisfaction. For example, among patients independent in ADLs at discharge, mean satisfaction scores were similar regardless of whether patients were dependent at admission (i.e., had improved) or independent at admission (i.e., remained stable) (79.6 vs 81.2, p=.46). Among patients dependent in ADLs at discharge, mean satisfaction scores were similar regardless of whether they were dependent at admission (i.e., remained stable) or independent at admission (i.e., had worsened) (74.0 vs 75.7, p=.63). These findings were similar using the measure of global health and in multivariate analyses.CONCLUSIONS: Patients with similar discharge health status have similar satisfaction regardless of whether that discharge health status represents stable health, improvement, or a decline in health status. The previously described positive association between patient satisfaction and health status more likely represents a tendency of healthier patients to report greater satisfaction with health care, rather than a tendency of patients who improve following an interaction with the health system to report greater satisfaction. This suggests that changes in health status and patient satisfaction are measuring different domains of hospital outcomes and quality. Comprehensive efforts to measure the outcomes and quality of hospital care will need to consider both patient satisfaction and changes in health status during hospitalization.

Do Acute Care for Elders Units Increase Hospital Costs? A Cost Analysis Using the Hospital Perspective

OBJECTIVE: To compare the hospital costs of caring for medical patients on a special unit designed to help older people maintain or achieve independence in self‐care activities with the costs of usual care.

When doctors marry doctors: a survey exploring the professional and family lives of young physicians.

Men and women in dual-doctor families differed from other physicians in many aspects of their professional and family lives, but they achieved their career and family goals as frequently.