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Predictors of functional recovery (FR) for elderly hospitalized patients in a geriatric evaluation and management unit (GEMU) in Taiwan
Archives of Gerontology and Geriatrics 50 Suppl. 1 (2010) S1–S5
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Predictors of functional recovery (FR) for elderly hospitalized patients in a geriatric evaluation and management unit (GEMU) in Taiwan Yi-Ming Chena,b,h , Ya-Wen Chuangb,e , Szu-Chia Liaob,d , Chu-Sheng Linb,f , Shu-Hui Yangb,c , Yih-Jing Tangb,g,i , Jaw-Ji Tsaia,b,g , Jong-Liang Lana,b,h,i,j , Der-Yuan Chena,b,h,i,j, * a Division
of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, No. 160, Section 3, Taichung-Kang Road, Taichung, 40705, Taiwan for Geriatrics and Gerontology, Taichung Veterans General Hospital, No. 160, Section 3, Taichung-Kang Road, Taichung, 40705, Taiwan c Department of Nursing, Taichung Veterans General Hospital, No. 160, Section 3, Taichung-Kang Road, Taichung, 40705, Taiwan d Division of Gastroenterology, Taichung Veterans General Hospital, No. 160, Section 3, Taichung-Kang Road, Taichung, 40705, Taiwan e Division of Nephrology, Taichung Veterans General Hospital, No. 160, Section 3, Taichung-Kang Road, Taichung, 40705, Taiwan f Department of Family Medicine, Taichung Veterans General Hospital, No. 160, Section 3, Taichung-Kang Road, Taichung, 40705, Taiwan g Department of Medical Education & Research, Taichung Veterans General Hospital, No. 160, Section 3, Taichung-Kang Road, Taichung, 40705, Taiwan h National Yang-Ming University, No. 155, Sec. 2, Linong Street, Taipei, 11272, Taiwan i National Chung-Hsing University, No. 250, Kuo Kuang Road, Taichung, 40227, Taiwan j Chung Shan Medical University, No. 110, Sec. 1, Jianguo N.Road, Taichung, 40201, Taiwan b Center
article info
abstract
Keywords: Functional recovery Timed up-and-go test Geriatric evaluation and management unit Predictors in elderly
Elderly patients who are hospitalized with acute illnesses frequently have adverse outcomes. To maintain functional independence, the geriatric evaluation and management unit (GEMU) was established to provide the opportunity for functional recovery (FR). This study’s aim was to investigate potential prognostic factors for functional improvement in a GEMU of Taichung Veterans General Hospital, Taiwan. A total of 117 elderly patients (age, 80.0±6.3 years, 84.6% males) were enrolled. A comprehensive geriatric assessment and functional status evaluation, including the functional reach test (FRT) and the timed up-and-go (TUG) test, were performed. FR was defined by a greater than 10% improvement in the Barthel Index (BI) before GEMU discharge. Lower BI (44.7±25.2 vs. 68.7±34.5, p < 0.001), lower instrumental activities of daily living (IADL) scores (1.8±1.5 vs. 3.5±2.6, p < 0.001), impaired FRT (83.3% vs. 63.5%, p = 0.028), and impaired TUG test (94.4% vs. 74.6%, p = 0.008) were predictive factors for functional improvement. On multivariate logistic regression, an impaired TUG test (Odds ratio = OR = 6.18, 95% confidence interval = 95% C.I. = 1.69–22.6, p = 0.006) was an independent variable associated with FR. The results indicate that elderly hospitalized patients, even with poor physical function, could benefit from geriatric integrated care delivered by a GEMU. © 2010 Elsevier Ireland Ltd. All rights reserved.
1. Introduction With advances in modern technology and medicine, we are now facing an aging world with a rapidly increasing elderly population. Older people often have multiple comorbidities and are, therefore, at higher risk of iatrogenic conditions and admission due to acute illness (Saltvedt et al., 2002). In frail elderly patients, hospitalization is associated with functional decline that can lead to premature institutionalization, caregiver burden, higher resource utilization, and death (Covinsky et al., 1997; Carlson et al., 1998). Measurements of functional status are better predictors of hospital outcome than admitting diagnosis, diagnosis-related groups, and * Corresponding author. Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, No. 160, Section 3, Taichung-Kang Road, Taichung, 40705, Taiwan. Tel.: +(886-4)-2359-2525 ext. 3330; fax: +(886-4)-2350-3285. E-mail address: [email protected] (D-Y. Chen). 0167-4943 /$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved.
standard indices of illness burden (Winograd et al., 1991; Inouye et al., 1993, 1998). For clinicians, the recognition of predictive factors for functional change is of great value to target high-risk frail elderly patients during hospitalization and start appropriate interventions. In elderly hospitalized patients, the functional trajectory, defined as the change in physical performance over a period of time, can be either decline or recovery, depending on the recruited patients’ characteristics and the treatments delivered. A recent systematic review of predictors for functional decline in elderly hospitalized patients reported a variety of clinical parameters, including age, diagnosis, activities of daily living (ADL), cognitive dysfunction, and residence (McCusker et al., 2002). However, the majority of prior studies focused on functional decline rather than functional recovery (FR), and studies targeting prognostic factors for functional gain have been lacking.
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With the advancing aging population, geriatric evaluation and management units (GEMUs) have been established worldwide to meet the special needs of elderly hospitalized patients (Palmer et al., 1994). Studies of GEMUs can be divided into two categories according to the type of patients enrolled: acutely ill (Category I) or in need of rehabilitation after stabilization of acute illness (Category II) (Saltvedt et al., 2002). In Category I, acute geriatric units have been shown by a recent meta-analysis to reduce functional decline and increase the probability of living at home after discharge compared with conventional hospital units, without increasing readmissions or health expenditures (Baztan ´ et al., 2009). Moreover, Miralles et al. (2003) identified that higher physical function, normal cognition, and better social-family support predicted the probability of home discharge in a geriatric convalescence unit, an example of Category II, in Spain. Since 1983, Taiwan has been an “advanced age” country, as defined by the United Nations, with the percentage of citizens over 65 years of age higher than 7% (United Nations Program on Aging, 2007). The rapidly increasing aging pressure in Taiwan prompted the development of GEMUs in tertiary medical centers over the entire island. The services delivered by GEMUs within the Veterans Affair System in Taiwan are based on principles of comprehensive geriatric assessment, team management, geriatric rehabilitation, and discharge planning that aim at promoting FR and physical independence for elderly inpatients. The aim of the present study was to investigate potential prognostic factors for FR of frail elderly hospitalized patients in the GEMU of Taichung Veterans General Hospital, Taiwan. 2. Subjects and methods 2.1. Study participants Frail elderly patients aged 65 years or older admitted to the GEMU of Taichung Veterans General Hospital were invited to participate. The enrollment criteria included those who were admitted due to geriatric syndromes, i.e., falls, intellectual failure, immobility, malnutrition, incontinence, etc. (Inouye et al., 2007) or development of ADL dependency within 2 weeks prior to admission because of acute illness, as well as those referred from other acute wards for rehabilitation after stabilization of an acute illness. Patients were excluded if they did not consent to participate, were completely physically dependent before admission, had cancer with metastasis, had known severe dementia before admission, had an expected survival of less than 6 months, or were experiencing rapid recovery of physical dependency. This study protocol was approved by the Ethics Committee of Clinical Research, Taichung Veterans General Hospital, and informed consent was obtained from each participant. 2.2. Study setting The GEMU in Taichung Veterans General Hospital is an 18-bed hospitalization facility devoted to the care of frail elderly patients with acute functional decline in a tertiary teaching hospital in central Taiwan. A nearby rehabilitation room for onsite physiotherapy and occupational therapy, along with visual calendars and clocks, provides accessibility for activities related to physical enablement and cognitive integrity. The staff of the GEMU consisted of two geriatricians, one case manager, one rehabilitation specialist, one psychiatrist, and two residents from the department of internal medicine and family medicine. The nurse members of the GEMU received formal training in geriatric nursing and skills for elderly care. The core members of the multi-disciplinary team in the GEMU included a physiotherapist, occupational therapist, dietitian, social worker, pharmacist, and psychologist. Meetings
were arranged once a week to report the assessments of different specialists, set goals, discuss various problems, and plan discharge. In general, rehabilitation in the GEMU aimed at improving ADL, walking independency, muscle strengthening, and balance training. Tailor-made rehabilitation plans were implemented by physiotherapists, occupational therapists, and nurses to ensure mobilization throughout the day and during holidays. 2.3. Comprehensive geriatric assessment Comprehensive geriatric assessments were performed for all patients within 48 hours of admission and before discharge from the GEMU. Basic ADL was evaluated using the Barthel Index (BI), which consists of 10 categories; including eating, toileting, personal hygiene, dressing, walking, and climbing stairs (Mahoney et al., 1965). FR was determined by improvement in the BI after GEMU intervention by more than 10%. The instrumental activities of daily living score (IADL) was used to evaluate more complex activities; namely shopping, housekeeping, finances, cooking, using public transportation, telephoning, laundry, and taking medicine correctly (Lawton and Brody, 1969). The mini-mental status exam (MMSE) was used as a screening tool for cognitive integrity (Folstein et al., 1975). The cut-off point for cognitive impairment was determined as between 23/24 for literate and 13/14 for illiterate patients (Guo et al., 1998). A 15-item geriatric depression scale (GDS, range 0–15) was used as a screening tool for depressive symptoms (Yesavage et al., 1982; Wong et al., 2002), and higher scores indicated more perceived symptoms. Nutritional status was assessed by a mininutritional assessment (MNA, range 0–30), and malnutrition was defined as an MNA less than 17 points (Guigoz et al., 1996). The timed up-and-go test (TUG) assessed physical function, and a cutoff value of 10 seconds is used to define mobility dysfunction (Podsiadlo and Richardson, 1991). Dynamic balance was evaluated by the functional reach test (FRT) (Duncan et al., 1990), and less than 6 inches of maximum forward reach is considered balance dysfunction. Co-morbid conditions were measured using the Charlson comorbidity index (CCI) (Charlson et al., 1987). 2.4. Statistical analysis Data in the text and tables are expressed as means ± S.D. The Statistical Package for the Social Sciences (SPSS) version 10.0 software (SPSS Ltd. Chicago, IL, USA) was used to perform all statistical analyses. Independent sample t-tests were used for comparisons between continuous variables as appropriate. Categorical variables were compared using the c2 -test. Multiple logistic regression analysis was used to identify independent factors for FR. All tests with p < 0.05 were considered statistically significant. 3. Results 3.1. Demographic data, laboratory investigations, and results of comprehensive geriatric assessments In total, 117 elderly inpatients (mean age, 80.0±6.3 years; 84.6% male) were enrolled (Table 1). The mean length of stay in the GEMU was 16.0±11.4 days. For all participants, the BI was 57.7±32.7, the IADL score was 2.7±2.3, and the MMSE was 23.6±6.2. In addition, 8.5% of subjects were considered to have delirium. The average BMI was 23.2±4.5 kg/m2 , and the mean MNA score was 22.4±3.8. The majority of participants (83.8%) had mobility dysfunction defined as an impaired TUG test, while 72.6% were classified as having impaired dynamic balance according to the FRT. The mean CCI was 2.9±2.2. The comorbidities and laboratory findings of the enrolled subjects are presented in Table 1.
Y-M. Chen et al. / Archives of Gerontology and Geriatrics 50 (2010) S1–S5 Table 1 Demographic data, characteristics of geriatric syndromes, and laboratory results in 117 elderly patients admitted to the GEMU, mean±S.D., or n(%)
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Table 2 Comparisons between subjects with and without FR in 117 elderly patients admitted to the GEMU, mean + S.D., or n(%)
Parameters
mean ± S.D., or n(%)
Parameters
With FR
Without FR
Age
80.0±6.3
Number
54
63
Sex (male)
99 (84.6)
Age
80.1±5.4
79.8±7.0
Length of stay (days)
16.0±11.4
Sex (males)
49 (90.7)
50 (79.4)
Length of stay (days)
17.7±10.4
14.5±12.1
22.4±3.6
24.0±5.1 #
Education (years) 0
22 (18.8)
BMI
1–9
56 (47.9)
Education (years)
>9
39 (33.3)
0
11 (20.4)
11 (17.5)
BMI
23.2±4.5
1–9
30 (55.6)
26 (41.3)
13 (24.1)
26 (41.3)
BI
57.7±32.7
BI
>9
44.7±25.2
68.7±34.5***
IADL
2.7±2.3
IADL
1.8±1.5
3.5±2.6***
MMSE
23.6±6.2
MMSE
20.4±6.3
22.5±7.2 #
Delirium
10 (8.5)
Delirium
4 (7.4)
6 (9.5)
GDS
5.39±3.83
GDS
5.83±3.59
5.78±4.18
MNA
22.4±3.8
MNA
20.2±4.2
21.1±6.0
98 (83.8)
Impaired TUG-test
51 (94.4)
47 (74.6)**
Impaired FRT
45 (83.3)
40 (63.5)*
CCI
2.9±2.2
2.9±2.2
Comprehensive geriatric assessment
Impaired TUG test Impaired FRT
85 (72.6)
CCI
2.9±2.2
#
Comorbidities Dementia
25 (21.4)
Congestive heart failure
6 (5.1)
Hypertension
75 (64.1)
CVA
27 (23.1)
DM
38 (32.5)
CKD
39 (33.3)
COPD
26 (22.2)
p < 0.10; *p < 0.05, **p < 0.01; ***p < 0.001
FR+ participants had a lower BMI (22.4±3.6 vs. 24.0±5.1, p = 0.053), lower BI (44.7±25.2 vs. 68.7±34.5, p < 0.001), lower IADL scores (1.8±1.5 vs. 3.5±2.6, p < 0.001), a greater likelihood of an impaired FRT (83.3% vs. 63.5%, p = 0.028), and an impaired TUG test (94.4% vs. 74.6%, p = 0.008). 3.3. Independent factors associated with FR
Laboratory investigations Hgb (g/dl)
11.77±2.20
Sodium (mg/dl)
138.2±4.67
Albumin (g/dl)
3.52±0.59
CRP (mg/dl)
2.63 (1.74–3.98)
Variables identified in Table 2 with p < 0.10, including BMI, MMSE, TUG test, and FRT, were analyzed further to identify independent variables for FR (Table 3). On multivariate logistic regression, the TUG test (OR = 6.18, 95% C.I. = 1.69–22.6, p = 0.006) was the only independent factor associated with FR.
3.2. Comparison between participants with and without FR Fifty-four patients had FR+ defined as an improvement in the BI by at least 10% after GEMU intervention, while 63 patients failed to improve (FR−) (Table 2). Compared with FR− participants,
4. Discussion The goal of geriatric inpatient services in Taichung Veterans General Hospital is to restore functional independency by means
Table 3 Independent factors for functional recovery in 117 elderly patients admitted to the GEMU Model B
Model A
Model C
OR (95% CI)
p=
OR (95% CI)
p=
BMI
0.91 (0.82–1.01)
0.064
0.91 (0.83–1.01)
0.063
MMSE
0.98 (0.92–1.04)
0.521
5.86 (1.58–21.7)
0.008
OR (95% CI)
p=
6.18 (1.69–22.6)
0.006
TUG-test intact
1.00
impaired
4.04 (0.89–18.5)
0.071
FRT intact
1.00
impaired
1.44 (0.46–4.52)
0.531
Model A: enter; Model B: backward selection, entry: p < 0.10; Model C: forward selection, entry: p < 0.10
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of comprehensive geriatric assessments, an intensive rehabilitation program, and a multidisciplinary approach. To facilitate patient selection for admission in the future, the aim of our study was to determine predictive factors of FR for frail elderly hospitalized patients. Previous studies have reported a variety of risk factors, including advanced age, poor baseline functional status, cognitive impairment, urinary incontinence, and pressure ulcers, for poor functional improvement in a postacute geriatric rehabilitation unit (Sze et al., 2000; Landi et al., 2002; Lin et al., 2003; Shyu et al., 2004; Denti et al., 2008). The results of the present study demonstrated that an impaired TUG test and recent loss of functional independence in terms of the BI and IADL were predictive factors for achieving FR from integrated geriatric services. However, differences in participants’ enrollment criteria, the definition of functional improvement, and interventions provided could partly explain the uneven results in the predictors between the present report and previous studies. The participants in the present study consisted of a mixture of frail elderly inpatients presenting with geriatric syndromes and acute functional decline within 2 weeks, while previous reports in the literature focused mainly on stroke and post-hip fracture patients. Moreover, outcome assessment in the present study was defined by improvement in the BI, which was similar to the post-hip fracture setting (Shyu et al., 2004). However, functional performance of personal ADL determined by the Minimum Data Set for Post-Acute Care (MDS-PAC) (Bernabei et al., 1998) assessment was adopted by Landi et al. (2002) in a geriatric hospital, while the functional independence measure (FIM) score (Deutsch et al., 1997) was used mostly for stroke inpatients (Lin et al., 2003; Denti et al., 2008). Therefore, our results are unique to this particular population and the integrated services provided. They may not be applicable to other elderly inpatients with different characteristics. Physical performance measurements have been reported to predict disability, nursing home placement, and death in the geriatric population (Reuben et al., 1992; Guralnik et al., 1995). The TUG test is one of the physical performance measures that have been validated for use in the rehabilitation setting and with orthopedic conditions (Freter and Fruchter, 2000; Kennedy et al., 2005). It also had been shown to be a valuable indicator for identifying community-dwelling elderly at risk for falls (ShumwayCook et al., 2000). Moreover, Brooks at al. (2006) also found that the TUG test correlated with functional ability, the FIM score, in elderly people participating in geriatric rehabilitation. Our results demonstrated that an impaired admission TUG test in elderly patients with acute functional decline is indicative of fair ADL recovery after the GEMU intervention. Participants with poor mobility function benefited more from our intervention, probably due to their more recent loss of ambulation independence, which implies more potential to improve after integrated geriatric services. In addition, various cut-off values between 10 and 25 seconds for the TUG test have been reported to discriminate between individuals at risk of falls (Nordin et al., 2008). Nevertheless, in the acute medical wards, the value of the TUG test lies more in whether the participant could complete the test and the reasons for the inability, rather than the time spent (Large et al., 2006). In the present study, the multidisciplinary care in the GEMU aimed at providing nutritional support, onsite rehabilitation, and discontinuing hazardous medication in frail elderly patients. Participants still had the opportunity to improve, even though they could not perform the TUG test well at admission. Parameters obtained from comprehensive geriatric assessment, including baseline functional status, cognitive impairment, pressure ulcers, and nutritional status, have been identified to be risk factors associated with functional decline during hospitalization (Inouye et al., 1993; Miralles et al., 2003; Chen et al., 2008). In addition, Landi et al. (2002) documented that impaired cognitive function
may be a negative predictor of FR in a prospective study of 244 elderly patients admitted to a hospital geriatric rehabilitation department after acute illness. The components of the BI and IADL are highly correlated with changes in the BI between admission and discharge. Therefore, the BI and IADL were not included in the multivariate logistic regression model. However, in the present study, participants with intact baseline physical function but poorer scores for the BI and IADL at admission achieved greater score changes in the BI. Our findings are in accordance with a previous report that found that stroke patients with more severe neurological deficits achieved greater improvements in physical function (Hershkovitz et al., 2006). There are some limitations to the present study. First, functional assessments before admission and over multiple time points after discharge were not included. More attention on the functional trajectory is needed. Second, the enrollment criteria varied from admission via emergency department because of acute illness to referral from other specialties for post-acute rehabilitation. The heterogeneity of the patients’ characteristics limits the applicability of the present result only to similar elderly patient groups. Third, the study population was small. However, the present results provide an evidence-based approach to patient selection for GEMU admission in the future. 5. Conclusions Integrated geriatric services delivered in a GEMU provided an opportunity to improve functional independence in frail elderly inpatients, even those more impaired in terms of BI and IADL. Patients with acute functional decline and inability to perform the TUG test benefit more from the multi-disciplinary approach and should be exposed to an intensive rehabilitation program. The geriatric multidisciplinary team may use the information to encourage even the more impaired elderly and to facilitate selection of patients with more rehabilitation potential. Conflict of interest statement None. Acknowledgements The authors are grateful to the Biostatistics Task Force of Taichung Veterans General Hospital, Taichung Taiwan, ROC, for statistical analysis for this study. References Baztan, ´ J.J., Suarez-Garc´ ´ ıa, F.M., Lopez-Arrieta, ´ J., Rodr´ıguez-Manas, ˜ L., Rodr´ıguezArtalejo, F., 2009. Effectiveness of acute geriatric units on functional decline, living at home, and case fatality among older patients admitted to hospital for acute medical disorders: meta-analysis. Br. Med. J. 338, b50. Bernabei, R., Landi, F., Manigrasso, L., Sgadari, A., 1998. MDS-PAC–Instruction Manual.: Pfizer Italia SpA. Rome, Italy. Brooks, D., Davis, A.M., Naglie, G., 2006. Validity of 3 physical performance measures in inpatient geriatric rehabilitation. Arch. Phys. Med. Rehabil. 87, 105–110. Carlson, J.E., Zocchi, K.A., Bettencourt, D.M., Gambrel, M.L., Freeman, J.L., Zhang, D., Goodwin, J.S., 1998. Measuring frailty in the hospitalized elderly: Concept of functional homeostasis. Am. J. Phys. Med. Rehabil. 77, 252–257. Charlson, M.E., Pompei, P., Ales, K.L., MacKenzie, C.R., 1987. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J. Chronic Dis. 40, 373–383. Chen, C.C., Wang, C., Huang, G.H., 2008. Functional trajectory 6 months posthospitalization: a cohort study of older hospitalized patients in Taiwan. Nurs. Res. 57, 93–100. Covinsky, K.E., Justice, A.C., Rosenthal, G.E., Palmer, R.M., Landefeld, C.S., 1997. Measuring prognosis and case mix in hospitalized elders. The importance of functional status. J. Gen. Intern. Med. 12, 203–208. Denti, L., Agosti, M., Franceschini, M., 2008. Outcome predictors of rehabilitation for first stroke in the elderly. Eur. J. Phys. Rehabil. Med. 44, 3–11.
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Predictors of functional recovery (FR) for elderly hospitalized patients in a geriatric evaluation and management unit (GEMU) in Taiwan Yi-Ming Chena,b,h , Ya-Wen Chuangb,e , Szu-Chia Liaob,d , Chu-Sheng Linb,f , Shu-Hui Yangb,c , Yih-Jing Tangb,g,i , Jaw-Ji Tsaia,b,g , Jong-Liang Lana,b,h,i,j , Der-Yuan Chena,b,h,i,j, * a Division
of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, No. 160, Section 3, Taichung-Kang Road, Taichung, 40705, Taiwan for Geriatrics and Gerontology, Taichung Veterans General Hospital, No. 160, Section 3, Taichung-Kang Road, Taichung, 40705, Taiwan c Department of Nursing, Taichung Veterans General Hospital, No. 160, Section 3, Taichung-Kang Road, Taichung, 40705, Taiwan d Division of Gastroenterology, Taichung Veterans General Hospital, No. 160, Section 3, Taichung-Kang Road, Taichung, 40705, Taiwan e Division of Nephrology, Taichung Veterans General Hospital, No. 160, Section 3, Taichung-Kang Road, Taichung, 40705, Taiwan f Department of Family Medicine, Taichung Veterans General Hospital, No. 160, Section 3, Taichung-Kang Road, Taichung, 40705, Taiwan g Department of Medical Education & Research, Taichung Veterans General Hospital, No. 160, Section 3, Taichung-Kang Road, Taichung, 40705, Taiwan h National Yang-Ming University, No. 155, Sec. 2, Linong Street, Taipei, 11272, Taiwan i National Chung-Hsing University, No. 250, Kuo Kuang Road, Taichung, 40227, Taiwan j Chung Shan Medical University, No. 110, Sec. 1, Jianguo N.Road, Taichung, 40201, Taiwan b Center
article info
abstract
Keywords: Functional recovery Timed up-and-go test Geriatric evaluation and management unit Predictors in elderly
Elderly patients who are hospitalized with acute illnesses frequently have adverse outcomes. To maintain functional independence, the geriatric evaluation and management unit (GEMU) was established to provide the opportunity for functional recovery (FR). This study’s aim was to investigate potential prognostic factors for functional improvement in a GEMU of Taichung Veterans General Hospital, Taiwan. A total of 117 elderly patients (age, 80.0±6.3 years, 84.6% males) were enrolled. A comprehensive geriatric assessment and functional status evaluation, including the functional reach test (FRT) and the timed up-and-go (TUG) test, were performed. FR was defined by a greater than 10% improvement in the Barthel Index (BI) before GEMU discharge. Lower BI (44.7±25.2 vs. 68.7±34.5, p < 0.001), lower instrumental activities of daily living (IADL) scores (1.8±1.5 vs. 3.5±2.6, p < 0.001), impaired FRT (83.3% vs. 63.5%, p = 0.028), and impaired TUG test (94.4% vs. 74.6%, p = 0.008) were predictive factors for functional improvement. On multivariate logistic regression, an impaired TUG test (Odds ratio = OR = 6.18, 95% confidence interval = 95% C.I. = 1.69–22.6, p = 0.006) was an independent variable associated with FR. The results indicate that elderly hospitalized patients, even with poor physical function, could benefit from geriatric integrated care delivered by a GEMU. © 2010 Elsevier Ireland Ltd. All rights reserved.
1. Introduction With advances in modern technology and medicine, we are now facing an aging world with a rapidly increasing elderly population. Older people often have multiple comorbidities and are, therefore, at higher risk of iatrogenic conditions and admission due to acute illness (Saltvedt et al., 2002). In frail elderly patients, hospitalization is associated with functional decline that can lead to premature institutionalization, caregiver burden, higher resource utilization, and death (Covinsky et al., 1997; Carlson et al., 1998). Measurements of functional status are better predictors of hospital outcome than admitting diagnosis, diagnosis-related groups, and * Corresponding author. Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, No. 160, Section 3, Taichung-Kang Road, Taichung, 40705, Taiwan. Tel.: +(886-4)-2359-2525 ext. 3330; fax: +(886-4)-2350-3285. E-mail address: [email protected] (D-Y. Chen). 0167-4943 /$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved.
standard indices of illness burden (Winograd et al., 1991; Inouye et al., 1993, 1998). For clinicians, the recognition of predictive factors for functional change is of great value to target high-risk frail elderly patients during hospitalization and start appropriate interventions. In elderly hospitalized patients, the functional trajectory, defined as the change in physical performance over a period of time, can be either decline or recovery, depending on the recruited patients’ characteristics and the treatments delivered. A recent systematic review of predictors for functional decline in elderly hospitalized patients reported a variety of clinical parameters, including age, diagnosis, activities of daily living (ADL), cognitive dysfunction, and residence (McCusker et al., 2002). However, the majority of prior studies focused on functional decline rather than functional recovery (FR), and studies targeting prognostic factors for functional gain have been lacking.
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With the advancing aging population, geriatric evaluation and management units (GEMUs) have been established worldwide to meet the special needs of elderly hospitalized patients (Palmer et al., 1994). Studies of GEMUs can be divided into two categories according to the type of patients enrolled: acutely ill (Category I) or in need of rehabilitation after stabilization of acute illness (Category II) (Saltvedt et al., 2002). In Category I, acute geriatric units have been shown by a recent meta-analysis to reduce functional decline and increase the probability of living at home after discharge compared with conventional hospital units, without increasing readmissions or health expenditures (Baztan ´ et al., 2009). Moreover, Miralles et al. (2003) identified that higher physical function, normal cognition, and better social-family support predicted the probability of home discharge in a geriatric convalescence unit, an example of Category II, in Spain. Since 1983, Taiwan has been an “advanced age” country, as defined by the United Nations, with the percentage of citizens over 65 years of age higher than 7% (United Nations Program on Aging, 2007). The rapidly increasing aging pressure in Taiwan prompted the development of GEMUs in tertiary medical centers over the entire island. The services delivered by GEMUs within the Veterans Affair System in Taiwan are based on principles of comprehensive geriatric assessment, team management, geriatric rehabilitation, and discharge planning that aim at promoting FR and physical independence for elderly inpatients. The aim of the present study was to investigate potential prognostic factors for FR of frail elderly hospitalized patients in the GEMU of Taichung Veterans General Hospital, Taiwan. 2. Subjects and methods 2.1. Study participants Frail elderly patients aged 65 years or older admitted to the GEMU of Taichung Veterans General Hospital were invited to participate. The enrollment criteria included those who were admitted due to geriatric syndromes, i.e., falls, intellectual failure, immobility, malnutrition, incontinence, etc. (Inouye et al., 2007) or development of ADL dependency within 2 weeks prior to admission because of acute illness, as well as those referred from other acute wards for rehabilitation after stabilization of an acute illness. Patients were excluded if they did not consent to participate, were completely physically dependent before admission, had cancer with metastasis, had known severe dementia before admission, had an expected survival of less than 6 months, or were experiencing rapid recovery of physical dependency. This study protocol was approved by the Ethics Committee of Clinical Research, Taichung Veterans General Hospital, and informed consent was obtained from each participant. 2.2. Study setting The GEMU in Taichung Veterans General Hospital is an 18-bed hospitalization facility devoted to the care of frail elderly patients with acute functional decline in a tertiary teaching hospital in central Taiwan. A nearby rehabilitation room for onsite physiotherapy and occupational therapy, along with visual calendars and clocks, provides accessibility for activities related to physical enablement and cognitive integrity. The staff of the GEMU consisted of two geriatricians, one case manager, one rehabilitation specialist, one psychiatrist, and two residents from the department of internal medicine and family medicine. The nurse members of the GEMU received formal training in geriatric nursing and skills for elderly care. The core members of the multi-disciplinary team in the GEMU included a physiotherapist, occupational therapist, dietitian, social worker, pharmacist, and psychologist. Meetings
were arranged once a week to report the assessments of different specialists, set goals, discuss various problems, and plan discharge. In general, rehabilitation in the GEMU aimed at improving ADL, walking independency, muscle strengthening, and balance training. Tailor-made rehabilitation plans were implemented by physiotherapists, occupational therapists, and nurses to ensure mobilization throughout the day and during holidays. 2.3. Comprehensive geriatric assessment Comprehensive geriatric assessments were performed for all patients within 48 hours of admission and before discharge from the GEMU. Basic ADL was evaluated using the Barthel Index (BI), which consists of 10 categories; including eating, toileting, personal hygiene, dressing, walking, and climbing stairs (Mahoney et al., 1965). FR was determined by improvement in the BI after GEMU intervention by more than 10%. The instrumental activities of daily living score (IADL) was used to evaluate more complex activities; namely shopping, housekeeping, finances, cooking, using public transportation, telephoning, laundry, and taking medicine correctly (Lawton and Brody, 1969). The mini-mental status exam (MMSE) was used as a screening tool for cognitive integrity (Folstein et al., 1975). The cut-off point for cognitive impairment was determined as between 23/24 for literate and 13/14 for illiterate patients (Guo et al., 1998). A 15-item geriatric depression scale (GDS, range 0–15) was used as a screening tool for depressive symptoms (Yesavage et al., 1982; Wong et al., 2002), and higher scores indicated more perceived symptoms. Nutritional status was assessed by a mininutritional assessment (MNA, range 0–30), and malnutrition was defined as an MNA less than 17 points (Guigoz et al., 1996). The timed up-and-go test (TUG) assessed physical function, and a cutoff value of 10 seconds is used to define mobility dysfunction (Podsiadlo and Richardson, 1991). Dynamic balance was evaluated by the functional reach test (FRT) (Duncan et al., 1990), and less than 6 inches of maximum forward reach is considered balance dysfunction. Co-morbid conditions were measured using the Charlson comorbidity index (CCI) (Charlson et al., 1987). 2.4. Statistical analysis Data in the text and tables are expressed as means ± S.D. The Statistical Package for the Social Sciences (SPSS) version 10.0 software (SPSS Ltd. Chicago, IL, USA) was used to perform all statistical analyses. Independent sample t-tests were used for comparisons between continuous variables as appropriate. Categorical variables were compared using the c2 -test. Multiple logistic regression analysis was used to identify independent factors for FR. All tests with p < 0.05 were considered statistically significant. 3. Results 3.1. Demographic data, laboratory investigations, and results of comprehensive geriatric assessments In total, 117 elderly inpatients (mean age, 80.0±6.3 years; 84.6% male) were enrolled (Table 1). The mean length of stay in the GEMU was 16.0±11.4 days. For all participants, the BI was 57.7±32.7, the IADL score was 2.7±2.3, and the MMSE was 23.6±6.2. In addition, 8.5% of subjects were considered to have delirium. The average BMI was 23.2±4.5 kg/m2 , and the mean MNA score was 22.4±3.8. The majority of participants (83.8%) had mobility dysfunction defined as an impaired TUG test, while 72.6% were classified as having impaired dynamic balance according to the FRT. The mean CCI was 2.9±2.2. The comorbidities and laboratory findings of the enrolled subjects are presented in Table 1.
Y-M. Chen et al. / Archives of Gerontology and Geriatrics 50 (2010) S1–S5 Table 1 Demographic data, characteristics of geriatric syndromes, and laboratory results in 117 elderly patients admitted to the GEMU, mean±S.D., or n(%)
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Table 2 Comparisons between subjects with and without FR in 117 elderly patients admitted to the GEMU, mean + S.D., or n(%)
Parameters
mean ± S.D., or n(%)
Parameters
With FR
Without FR
Age
80.0±6.3
Number
54
63
Sex (male)
99 (84.6)
Age
80.1±5.4
79.8±7.0
Length of stay (days)
16.0±11.4
Sex (males)
49 (90.7)
50 (79.4)
Length of stay (days)
17.7±10.4
14.5±12.1
22.4±3.6
24.0±5.1 #
Education (years) 0
22 (18.8)
BMI
1–9
56 (47.9)
Education (years)
>9
39 (33.3)
0
11 (20.4)
11 (17.5)
BMI
23.2±4.5
1–9
30 (55.6)
26 (41.3)
13 (24.1)
26 (41.3)
BI
57.7±32.7
BI
>9
44.7±25.2
68.7±34.5***
IADL
2.7±2.3
IADL
1.8±1.5
3.5±2.6***
MMSE
23.6±6.2
MMSE
20.4±6.3
22.5±7.2 #
Delirium
10 (8.5)
Delirium
4 (7.4)
6 (9.5)
GDS
5.39±3.83
GDS
5.83±3.59
5.78±4.18
MNA
22.4±3.8
MNA
20.2±4.2
21.1±6.0
98 (83.8)
Impaired TUG-test
51 (94.4)
47 (74.6)**
Impaired FRT
45 (83.3)
40 (63.5)*
CCI
2.9±2.2
2.9±2.2
Comprehensive geriatric assessment
Impaired TUG test Impaired FRT
85 (72.6)
CCI
2.9±2.2
#
Comorbidities Dementia
25 (21.4)
Congestive heart failure
6 (5.1)
Hypertension
75 (64.1)
CVA
27 (23.1)
DM
38 (32.5)
CKD
39 (33.3)
COPD
26 (22.2)
p < 0.10; *p < 0.05, **p < 0.01; ***p < 0.001
FR+ participants had a lower BMI (22.4±3.6 vs. 24.0±5.1, p = 0.053), lower BI (44.7±25.2 vs. 68.7±34.5, p < 0.001), lower IADL scores (1.8±1.5 vs. 3.5±2.6, p < 0.001), a greater likelihood of an impaired FRT (83.3% vs. 63.5%, p = 0.028), and an impaired TUG test (94.4% vs. 74.6%, p = 0.008). 3.3. Independent factors associated with FR
Laboratory investigations Hgb (g/dl)
11.77±2.20
Sodium (mg/dl)
138.2±4.67
Albumin (g/dl)
3.52±0.59
CRP (mg/dl)
2.63 (1.74–3.98)
Variables identified in Table 2 with p < 0.10, including BMI, MMSE, TUG test, and FRT, were analyzed further to identify independent variables for FR (Table 3). On multivariate logistic regression, the TUG test (OR = 6.18, 95% C.I. = 1.69–22.6, p = 0.006) was the only independent factor associated with FR.
3.2. Comparison between participants with and without FR Fifty-four patients had FR+ defined as an improvement in the BI by at least 10% after GEMU intervention, while 63 patients failed to improve (FR−) (Table 2). Compared with FR− participants,
4. Discussion The goal of geriatric inpatient services in Taichung Veterans General Hospital is to restore functional independency by means
Table 3 Independent factors for functional recovery in 117 elderly patients admitted to the GEMU Model B
Model A
Model C
OR (95% CI)
p=
OR (95% CI)
p=
BMI
0.91 (0.82–1.01)
0.064
0.91 (0.83–1.01)
0.063
MMSE
0.98 (0.92–1.04)
0.521
5.86 (1.58–21.7)
0.008
OR (95% CI)
p=
6.18 (1.69–22.6)
0.006
TUG-test intact
1.00
impaired
4.04 (0.89–18.5)
0.071
FRT intact
1.00
impaired
1.44 (0.46–4.52)
0.531
Model A: enter; Model B: backward selection, entry: p < 0.10; Model C: forward selection, entry: p < 0.10
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of comprehensive geriatric assessments, an intensive rehabilitation program, and a multidisciplinary approach. To facilitate patient selection for admission in the future, the aim of our study was to determine predictive factors of FR for frail elderly hospitalized patients. Previous studies have reported a variety of risk factors, including advanced age, poor baseline functional status, cognitive impairment, urinary incontinence, and pressure ulcers, for poor functional improvement in a postacute geriatric rehabilitation unit (Sze et al., 2000; Landi et al., 2002; Lin et al., 2003; Shyu et al., 2004; Denti et al., 2008). The results of the present study demonstrated that an impaired TUG test and recent loss of functional independence in terms of the BI and IADL were predictive factors for achieving FR from integrated geriatric services. However, differences in participants’ enrollment criteria, the definition of functional improvement, and interventions provided could partly explain the uneven results in the predictors between the present report and previous studies. The participants in the present study consisted of a mixture of frail elderly inpatients presenting with geriatric syndromes and acute functional decline within 2 weeks, while previous reports in the literature focused mainly on stroke and post-hip fracture patients. Moreover, outcome assessment in the present study was defined by improvement in the BI, which was similar to the post-hip fracture setting (Shyu et al., 2004). However, functional performance of personal ADL determined by the Minimum Data Set for Post-Acute Care (MDS-PAC) (Bernabei et al., 1998) assessment was adopted by Landi et al. (2002) in a geriatric hospital, while the functional independence measure (FIM) score (Deutsch et al., 1997) was used mostly for stroke inpatients (Lin et al., 2003; Denti et al., 2008). Therefore, our results are unique to this particular population and the integrated services provided. They may not be applicable to other elderly inpatients with different characteristics. Physical performance measurements have been reported to predict disability, nursing home placement, and death in the geriatric population (Reuben et al., 1992; Guralnik et al., 1995). The TUG test is one of the physical performance measures that have been validated for use in the rehabilitation setting and with orthopedic conditions (Freter and Fruchter, 2000; Kennedy et al., 2005). It also had been shown to be a valuable indicator for identifying community-dwelling elderly at risk for falls (ShumwayCook et al., 2000). Moreover, Brooks at al. (2006) also found that the TUG test correlated with functional ability, the FIM score, in elderly people participating in geriatric rehabilitation. Our results demonstrated that an impaired admission TUG test in elderly patients with acute functional decline is indicative of fair ADL recovery after the GEMU intervention. Participants with poor mobility function benefited more from our intervention, probably due to their more recent loss of ambulation independence, which implies more potential to improve after integrated geriatric services. In addition, various cut-off values between 10 and 25 seconds for the TUG test have been reported to discriminate between individuals at risk of falls (Nordin et al., 2008). Nevertheless, in the acute medical wards, the value of the TUG test lies more in whether the participant could complete the test and the reasons for the inability, rather than the time spent (Large et al., 2006). In the present study, the multidisciplinary care in the GEMU aimed at providing nutritional support, onsite rehabilitation, and discontinuing hazardous medication in frail elderly patients. Participants still had the opportunity to improve, even though they could not perform the TUG test well at admission. Parameters obtained from comprehensive geriatric assessment, including baseline functional status, cognitive impairment, pressure ulcers, and nutritional status, have been identified to be risk factors associated with functional decline during hospitalization (Inouye et al., 1993; Miralles et al., 2003; Chen et al., 2008). In addition, Landi et al. (2002) documented that impaired cognitive function
may be a negative predictor of FR in a prospective study of 244 elderly patients admitted to a hospital geriatric rehabilitation department after acute illness. The components of the BI and IADL are highly correlated with changes in the BI between admission and discharge. Therefore, the BI and IADL were not included in the multivariate logistic regression model. However, in the present study, participants with intact baseline physical function but poorer scores for the BI and IADL at admission achieved greater score changes in the BI. Our findings are in accordance with a previous report that found that stroke patients with more severe neurological deficits achieved greater improvements in physical function (Hershkovitz et al., 2006). There are some limitations to the present study. First, functional assessments before admission and over multiple time points after discharge were not included. More attention on the functional trajectory is needed. Second, the enrollment criteria varied from admission via emergency department because of acute illness to referral from other specialties for post-acute rehabilitation. The heterogeneity of the patients’ characteristics limits the applicability of the present result only to similar elderly patient groups. Third, the study population was small. However, the present results provide an evidence-based approach to patient selection for GEMU admission in the future. 5. Conclusions Integrated geriatric services delivered in a GEMU provided an opportunity to improve functional independence in frail elderly inpatients, even those more impaired in terms of BI and IADL. Patients with acute functional decline and inability to perform the TUG test benefit more from the multi-disciplinary approach and should be exposed to an intensive rehabilitation program. The geriatric multidisciplinary team may use the information to encourage even the more impaired elderly and to facilitate selection of patients with more rehabilitation potential. Conflict of interest statement None. Acknowledgements The authors are grateful to the Biostatistics Task Force of Taichung Veterans General Hospital, Taichung Taiwan, ROC, for statistical analysis for this study. References Baztan, ´ J.J., Suarez-Garc´ ´ ıa, F.M., Lopez-Arrieta, ´ J., Rodr´ıguez-Manas, ˜ L., Rodr´ıguezArtalejo, F., 2009. Effectiveness of acute geriatric units on functional decline, living at home, and case fatality among older patients admitted to hospital for acute medical disorders: meta-analysis. Br. Med. J. 338, b50. Bernabei, R., Landi, F., Manigrasso, L., Sgadari, A., 1998. MDS-PAC–Instruction Manual.: Pfizer Italia SpA. Rome, Italy. Brooks, D., Davis, A.M., Naglie, G., 2006. Validity of 3 physical performance measures in inpatient geriatric rehabilitation. Arch. Phys. Med. Rehabil. 87, 105–110. Carlson, J.E., Zocchi, K.A., Bettencourt, D.M., Gambrel, M.L., Freeman, J.L., Zhang, D., Goodwin, J.S., 1998. Measuring frailty in the hospitalized elderly: Concept of functional homeostasis. Am. J. Phys. Med. Rehabil. 77, 252–257. Charlson, M.E., Pompei, P., Ales, K.L., MacKenzie, C.R., 1987. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J. Chronic Dis. 40, 373–383. Chen, C.C., Wang, C., Huang, G.H., 2008. Functional trajectory 6 months posthospitalization: a cohort study of older hospitalized patients in Taiwan. Nurs. Res. 57, 93–100. Covinsky, K.E., Justice, A.C., Rosenthal, G.E., Palmer, R.M., Landefeld, C.S., 1997. Measuring prognosis and case mix in hospitalized elders. The importance of functional status. J. Gen. Intern. Med. 12, 203–208. Denti, L., Agosti, M., Franceschini, M., 2008. Outcome predictors of rehabilitation for first stroke in the elderly. Eur. J. Phys. Rehabil. Med. 44, 3–11.
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