Elderly likely to decline after hospitalization

By Camille Mojica Rey

Elderly patients may receive life-saving care by being hospitalized, but one of the costs may be a loss of independence after returning home. That is the finding of a study by researchers at the San Francisco VA Medical Center (SFVAMC).

“More than a third of the elderly in our study were less able to care for themselves after being in the hospital than before the illness that caused their hospitalization in the first place,” said the study’s lead author, Kenneth Covinsky, MD, MPH, staff physician at the SFVAMC and UCSF assistant professor of medicine.

The study appears in the April issue of the Journal of the American Geriatric Society.
Physicians and caregivers should make preparations for post-hospitalization care that assumes a loss of function, Covinsky said. “We need to be aware that hospitalization is a critical juncture as far as older people being able to take care of themselves,” he said.

A principal goal of the care of older patients is maintaining the ability to perform basic self-care activities. These activities, known as “activities of daily living,” or ADLs, include a standard list: bathing, dressing, using a toilet, transferring out of bed or chair, and eating without assistance. Loss of independence in these activities increases the likelihood of institutionalization, increases the burden on caregivers, and often means higher healthcare costs. The inability to perform ADLs can also hasten death.

For these reasons, researchers wanted to take a closer look at what seemed to be an observation made by both clinicians and patients’ family members: the elderly were often more dependent after being hospitalized.

Researchers used functional data from elderly patients participating in two randomized controlled studies of an intervention to improve ADL outcomes in hospitalized medical patients over the age of 70. The studies were conducted between 1993 and 1997 at University Hospitals of Cleveland and Akron City Hospital, both in Ohio. A total of 2,293 patients were eligible for inclusion in the study.

Patients or family members were interviewed at the time of hospital admission and discharge as to whether they could perform the standard list of ADLs. Upon admission, patients or surrogates were also asked about the performance of ADLs two weeks prior as a way of determining baseline function.

Thirty-five percent of patients declined in ADL function between baseline and discharge, including 12 percent who did not decline between baseline and admission and 18 percent who declined between baseline and admission and were unable to recover their baseline function. The remaining 5 percent declined between baseline and admission and experienced additional decline prior to discharge.

The rate for functional decline was over 50 percent for those patients 85 and older.

The current study is the most-comprehensive report to date of changes in functional status before and during hospitalization, its authors said. The study’s strengths include a large cohort size, validated measures to assess functional status, a large number of patients in the oldest age category (85 and older) and the ability to distinguish between functional changes before and after admission to a hospital.

The results of the study indicate that clinicians must closely monitor the functional status of their older patients, especially the more elderly ones, the authors conclude. They also say that further study is needed to determine if hospitalization-related decline can be prevented. But, Covinsky said, awareness on the part of health care providers can go a long way to mitigating loss of function in the meantime. “We need to think about strategies for rehabilitation for older people when they are hospitalized,” he said.

Additional authors on the study include C. Seth Landefeld, MD, SFVAMC and UCSF professor of medicine; Anita L. Stewart, PhD, UCSF professor in residence; Robert M. Palmer, MD, MPH, Cleveland Clinic Foundation, Cleveland, Ohio; Richard H. Fortinsky, PhD, University of Connecticut Health Center, Farmington, Connecticut; Steven R. Counsell, MD, and Denize Kresevic, RN, PhD, Indiana University, Indianapolis, Indiana; and Christoper J. Burant, MA, Case Western University, Cleveland, Ohio.

This research was supported in part by grants from the National Institute on Aging to the Claude Pepper Older Americans Independence Center at Case Western Reserve University, The Summa Health System Foundation to Akron City Hospital, The John A. Hartford Foundation to the University of California, San Francisco. Covinsky was supported in part by an independent investigator award from the Agency for Healthcare Research and Quality and is a Paul Beeson Faculty Scholar in Aging Research. Landefeld was supported in part by a Geriatrics Academic Leadership Award from the National Institute on Aging.