Steve R. Fisher

Ambulatory Activity of Older Adults Hospitalized with Acute Medical Illness

OBJECTIVES: To describe the amount and patterns of ambulatory activity in hospitalized older adults over consecutive hospital days.

Mobility After Hospital Discharge as a Marker for 30-Day Readmission

BACKGROUND Little is known about older patients mobility soon after discharge home from an acute hospitalization. We examined daily postdischarge mobility levels as marker of overall health and response to in-hospital treatment in older medicine patients. METHODS One hundred and eleven ambulatory men and women aged 65 years and older hospitalized with an acute medical illness and discharged to home were studied. Patients received an ankle-worn accelerometer during hospitalization and wore it continually for up to 1 week after discharge. Total number of steps taken per day was assessed. The primary outcome was all-cause 30-day readmission. RESULTS Thirteen (11.7%) participants were readmitted within 30 days of discharge. There was a significant association between mean daily steps taken postdischarge and 30-day readmission (odds ratio = 0.85, 95% confidence interval = 0.72-0.99, and p = .04; odds ratio and confidence intervals were calculated for 500-step intervals). Though not statistically significant in the fully adjusted model (odds ratio = 0.83, 95% confidence interval = 0.71-1.02, and p = .08), mean daily steps was the strongest predictor among known readmission risk factors. The least active participants postdischarge were significantly more likely to be older (p = .02), be not married (p = .02), use a cane or walker prior to admission (p < .01), have longer lengths of hospital stay (p = .02), and be readmitted (p = .05). CONCLUSIONS Mobility level soon after discharge home shows promise as a simple physical biomarker of overall health and risk of 30-day readmission in older patients.

Short Physical Performance Battery in Hospitalized Older Adults

Background and aims: The objectives of this study were to determine if Short Physical Performance Battery (SPPB) information could be collected in a hospitalized older patient population, and to assess associations between SPPB scores and sociodemographic characteristics and clinical measures. Methods: A cross sectional design was used that included 90 adults aged 65 years or older admitted to an Acute Care for Elders unit. Patient information was collected within 24 hours of hospitalization. SPPB was scored using established criteria in older persons living in the community and revised criteria based on older persons hospitalized with acute illness. Results: The mean age was 75.3 (SD 7.1) years; 61% were women. The SPPB can be safely and reliably administered to hospitalized elderly patients. No injuries or adverse events occurred. Hospital SPPB scoring criteria better distributed the overall range of performance for older patients than community SPPB scoring criteria. In multivariate regression analyses, increasing age (p=0.007), length of stay (p=0.02), comorbidities (p=0.04), and cognition (p=0.02) were significantly and inversely associated with SPPB when scored using hospital based scoring criteria. Only age (p=0.02) was significantly associated with SPPB when using community based scoring criteria. Conclusions: This study showed that a SPPB can be reliably collected in hospitalized older patients. The study further suggests that hospital based SPPB scoring criteria may be more appropriate for an older patient population.

Factors that differentiate level of ambulation in hospitalised older adults

SIR—The adverse effects of low mobility in older hospitalised persons are well documented [1, 2]. The amount of time patients are limited to a bed or chair is an independent predictor of functional decline even after controlling for illness severity [3]. Ambulation is a potentially simple intervention to reduce low mobility in-hospital. A number of factors, however, can interact to influence how much a patient actually walks. Identifying factors associated with varied levels of ambulation would help clinicians identify older patients at risk for low levels of mobility. Although, previous studies have investigated perceived barriers to ambulation during hospitalisation from the perspectives of older patients and their primary nurses and physicians [4], no study has examined relevant factors using direct measures of ambulatory activity such as step counts. We recently demonstrated that accelerometer technology can be used to collect continuous information on patient mobility in hospitalised older persons [5]. For this study, our objective was to identify subgroups of patients with shared clinical profiles who differed with respect to mean daily ambulation.

Patterns and correlates of depression in hospitalized older adults

Depression is often associated with illness or injury requiring acute hospitalization, particularly in older adults. We sought to determine patterns of change in depressive symptoms in older adults from hospitalization to 3 months post discharge and to examine factors associated with depressive symptoms 3 months after discharge. The study included 197 patients aged 65 years or older hospitalized with an acute medical illness. Sociodemographic and clinical measures, including depressive symptoms using the Center for Epidemiologic Study-Depression (CES-D) scale, were collected during the inpatient stay and at 3 months post discharge. Mean age was 75.3 ± 7.5 (± S.D.) years, 59% of the participants were female, 61% unmarried, and 72% had a high school education or more. High depressive symptoms (i.e., CES-D ≥ 16) were reported in 37% at admission. Of the 8% depressed at follow-up, 81% were also depressed at admission; 19% were new cases of depression. Depressive symptoms 3 months post-hospitalization were significantly associated with follow-up daily living skills (p=0.001) and social support (p<0.0001). Patients with persistent depressive symptoms make up the majority of post-hospitalization depression cases. Post-hospitalization social support and daily living skills appear to be important in the management of follow-up depressive symptoms.

Pilot Study Examining the Association Between Ambulatory Activity and Falls Among Hospitalized Older Adults

OBJECTIVE To examine the ambulatory activity of older patients who had a documented fall during hospitalization for acute illness. DESIGN A retrospective case-control design was used in a pilot study of patients (n=10; ≥65y) who had a documented fall during their hospital stay and matched controls (n=25) who did not fall. SETTING Acute care medical/surgical unit. PARTICIPANTS Men and women 65 years and older who wore a step activity monitor while hospitalized. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Fall incidents during the hospital stay were documented by the nurse in a standardized patient safety event report in accordance with hospital policy. The number of steps per 24-hour interval, time spent walking, and total number of activity episodes were determined for patients and controls. RESULTS On average ± SD, patients who fell took 480.3 ± 432.2 steps per hospital day, spent 53.8 ± 36.9 minutes walking, and engaged in 25.8 ± 16.9 episodes of activity. Mean daily steps, time spent walking, and number of activity episodes for patients who did not fall were 680.1 ± 876.0, 50.1 ± 58.6, and 21.6 ± 23.8, respectively. Logistic regression results indicated no association between the fall outcome and mean daily steps (odds ratio=.95; 95% confidence interval, 0.84-1.06). CONCLUSIONS Ambulatory activity among patients who fell varied widely. Mean daily steps, time spent walking, and number of episodes of activity were comparable with matched controls who did not fall. Patient falls were more likely to be associated with cognitive and hospital environmental factors than actual amount of walking.

Inpatient Walking Activity to Predict Readmission in Older Adults

OBJECTIVE To compare the 30-day readmission predictive power of in-hospital walking activity and in-hospital activities of daily living (ADLs) in older acutely ill patients. In addition, we sought to identify preliminary walking thresholds that could support the targeting of interventions aimed at minimizing rehospitalizations. DESIGN Prospective, observational clinical cohort study. Step counts during hospitalization were assessed via accelerometry. ADL function was assessed within 48 hours of admission. SETTING Acute care hospital. PARTICIPANTS One hundred sixty-four ambulatory persons aged 65 years and older admitted to the hospital from the community with an acute medical illness. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Readmission back to the index hospital (yes vs no) within 30 days of discharge. RESULTS Twenty-six patients (15.8%) were readmitted within 30 days of discharge. Walking activity during hospitalization was more strongly and significantly associated with 30-day readmission (odds ratio=0.90; 95% confidence interval, 0.82-0.98) than ADL function (odds ratio=0.45; 95% confidence interval, 0.14-1.45) after adjusting for relevant readmission risk factors. The predictive accuracy (area under the curve) was highest for models that included walking activity and changed little with the addition of ADLs. A walking threshold of 275 steps or more per day identified patients at reduced 30-day readmission risk. CONCLUSIONS Walking activity was a stronger predictor of readmission than ADLs. Monitoring patient activity during hospitalization may provide clinicians with valuable information on early readmission risk not captured by measures of ADLs. Further study is needed to replicate these findings and monitor walking activity posthospitalization to further advance our understanding of readmission risk.

Identifying effective and feasible interventions to accelerate functional recovery from hospitalization in older adults: A randomized controlled pilot trial

Hospitalization induces functional decline in older adults. Many geriatric patients fail to fully recover physical function after hospitalization, which increases the risk of frailty, disability, dependence, re-hospitalization, and mortality. There is a lack of evidence-based therapies that can be implemented following hospitalization to accelerate functional improvements. The aims of this Phase I clinical trial are to determine 1) the effect size and variability of targeted interventions in accelerating functional recovery from hospitalization and 2) the feasibility of implementing such interventions in community-dwelling older adults. Older patients (≥65years, n=100) will be recruited from a single site during hospitalization for an acute medical condition. Subjects will be randomized to one of five interventions initiated immediately upon discharge: 1. protein supplementation, 2. in-home rehabilitation plus placebo supplementation, 3. in-home rehabilitation plus protein supplementation, 4. single testosterone injection, or 5. isocaloric placebo supplementation. Testing will occur during hospitalization (baseline) and at 1 and 4weeks post-discharge. Each testing session will include measures of muscle strength, physical function/performance, body composition, and psychological function. Physical activity levels will be continuously monitored throughout study participation. Feasibility will be determined through collection of the number of eligible, contacted, and enrolled patients; intervention adherence and compliance; and reasons for declining enrollment and study withdrawal. This research will determine the feasibility of post-hospitalization strategies to improve physical function in older adults. These results will also provide a foundation for performing larger, multi-site clinical trials to improve physical function and reduce readmissions in geriatric patents.

Chair Rise Ability and Length of Stay in Hospitalized Older Adults

To the Editor: Length of stay is an important indicator of recovery associated with acute hospitalization.1 Typically, combinations of variables such as advanced age, frailty status, fall history, immobility, and malnutrition are used as a general set of risk indicators for prolonged length of stay.2,3 This study sought to determine whether a simple, objective test—ability to rise once from a chair—could identify older patients at risk for longer length of stay. Patients were categorized into those able and unable to perform a chair rise task. Associations between chair rise ability and length of stay were examined, adjusting for demographic, functional, and clinical measures. A convenience sample of 83 patients aged 65 and older admitted to an Acute Care for Elders (ACE) unit was studied. Patients were excluded from participation if they were transferred from a nursing home or unable to get out bed, had a stroke or lower extremity trauma-related diagnosis, were cognitively unable to provide their own informed consent, or reported one or more limitations in activities of daily living 2 weeks before admission. Patients were asked to stand up once from a straight-backed, regular-height (17 cm) chair with their hands folded across their chest. A licensed physical therapist performed the assessment within 24 hours of admission. If the patient was able to stand up once without the use of his or her hands, the test was recorded as successful and otherwise as unsuccessful. Interviewers trained in clinical research also collected patient information in a face-to-face interview and using medical chart review. To compare the association between length of stay and chair rise ability, three generalized estimating equation models were computed using a poisson distribution. The first model included chair rise ability, the second model added demographic measures, and the third model added functional and clinical measures. Mean age ± standard deviation was 74.2 ± 6.2 (range 65–89); 57.8% were women. Forty-two patients (50.6%) were unable to perform the chair rise task. The unadjusted mean length of stay for patients who could not perform the chair rise task was 1.5 days longer than for those who could perform the task (3.0 ± 1.7 vs 4.5 ± 2.6 days). Table 1 shows associations between length of stay and chair rise ability with and without adjustment for relevant covariates. Odd ratios and 95% confidence intervals are presented for each of the three models. Only chair rise ability was significantly associated with length of stay in all models. Table 1 Generalized Linear Regression Models Assessing the Association Between Length of Hospital Stay and Chair Rise Ability (N = 83) The study showed chair rise ability assessed within the first 24 hours of hospital admission was significantly associated with length of stay. After adjusting for relevant covariates, patients who could not perform the chair rise task had, on average, expected lengths of stay of approximately 45% longer than those who could. Recent research showing linkages between measures of lower-body performance and the overall health and well-being of older adults supports the use of chair rise ability as a clinical risk indicator in an acute care setting.4 Rising from a seated to standing position is known to be a bio-mechanically challenging activity.5 It requires threshold levels of muscular strength and adequate balance control. At the time of chair transfer, hip torques can be much larger than those required for walking or stair climbing,6,7 and the body is in a statically unstable position.6,8,9 The findings of the current study indicate that the inability to rise once from a chair reflects a state of functional and physiological vulnerability in older patients, placing them at risk for adverse outcomes during hospitalization, which could lead to complications related to the longer stay.10 Although the sample was not randomly selected, men and women were equally represented, and all patients included in the analyses reported no activity of daily living limitations 2 weeks before hospitalization. Factors associated with illness severity that may have influenced length of stay were also not identified; however, because the chair rise assessment was performed within 24 hours of admission, the association between chair rise ability and length of stay suggests that patient ability or inability to perform the task acted as a proxy for overall health and vitality. The chair rise task described in this study is an easily interpretable, objective measure that any member of the healthcare team can perform. The inability to rise once from a chair without use of the hands may be one way to characterize older patients who may be at risk for longer length of hospital stay, which has implications for decisions regarding early preventative measures, inpatient therapy services, and potential postdischarge level of care.

A randomized controlled pilot trial of interventions to improve functional recovery after hospitalization in older adults: Feasibility and adherence

Background Hospitalization is a major risk factor for functional decline, disability, loss of independence, and mortality in older adults. Evidence-based interventions to improve functional recovery from hospitalization are difficult to evaluate and implement in geriatric patients. The goal of this pilot study was to test the feasibility of recruiting geriatric inpatients and implementing pragmatic interventions to improve physical function following hospitalization. Methods Enrolled subjects were randomized to one of five 30-day posthospitalization interventions: isocaloric placebo (P), whey protein supplement (W), in-home rehabilitation+placebo (R+P), rehabilitation+whey protein (R+W), or testosterone (T). Data were collected from a single-site university hospital to determine: (i) institution-based feasibility (nonmodifiable factors including number of patients screened, eligible, contacted) and (ii) patient-based feasibility (modifiable factors including number of patients refusing, enrolled, randomized, intervention adherence, and withdrawal). Results From January 2014 to July 2016, 4,533 patients were chart screened; 594 (13.1%) were eligible to participate; 384 eligible subjects were contacted; 113 were enrolled; and 100 were randomized. Supplement adherence was 75% and was not different by age, education, level of independence, depression, supplement type, or dual intervention, but was significantly higher in subjects who completed the intervention (p < .01). Rehabilitation session adherence was 77% and did not vary significantly by age, education, level of independence, depression, or supplement type, but was significantly higher for sessions directly supervised (p < .01). Adherence was 100% in the testosterone arm with 94.7% of injections given within 24 hours of discharge. Conclusions Findings from this clinical trial indicate that posthospitalization interventions in geriatric patients are feasible at both the institution and patient level.