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Prognosis for Functional Deterioration and Functional Improvement in Late Life Among Community-Dwelling Older Persons
Commentary
Prognosis for Functional Deterioration and Functional Improvement in Late Life Among Community-Dwelling Older Persons Paul Gerrard, MD The article by Stineman et al [1] in this issue of PM&R revisits the topic of the relationships among change in functional status, chronic disease burden, and mortality in older adults. We have witnessed many developments in the topic of functional assessment in older adults during the past decade, such as the characterizations of trajectories of decline approaching mortality [2] and the development of physical function staging tools by several different groups [3], including an activities of daily living (ADL) staging system developed previously by Stineman and her collaborators [4]. Stineman et al’s ADL staging system was credited as intellectual progress toward something referred to as the Functional Reserve Assessment Map for Elders (FRAME), an as-of-yet unidentified staging system that has been called for and that would characterize functional status in older adults, in a manner similar to that of the 4-stage heart failure classification, to help us better understand functional decline and to identify effective interventions [3]. The present study extends Stineman et al’s earlier work on functional staging by looking at transitions between ADL stages longitudinally in community-dwelling older adults during a 2-year time frame, and demonstrating among their analyses significant relationships between functional stage transitions and chronic disease burden. A useful FRAME staging system was described as an instrument that is clinically applicable, based on easily obtainable information relating to function, and able to be used to determine the relationship of various diseases to functional decline [3]. Stineman et al’s ADL staging system is no doubt based on functional data that are easily obtained, and the present study adds to this previous work, by showing that it also has clinical applicability as a prognostic tool and that it can be used to study the relationships of particular disease processes to functional decline, thus meeting the proposed criteria for a FRAME staging system. A remaining issue of interest is whether functional status in older adults should be staged by using other domains in addition to ADL performance, as Dr. Stineman et al have done for the inpatient rehabilitation population [5]. For example, cognitive status is an established predictor of functional dependence that is independent of physical functioning [6] and, as such, might warrant a staging domain distinct from the largely physical domain of ADL function. As accountable care organizations begin to populate the health care landscape, meaningful assessments of health status will become especially important for resource allocation decisions. To make these assessments efficiently, tools such as ADL staging will become increasingly important because of their abilities to distill a multidimensional trait such as functional status into meaningful strata.
REFERENCES 1. Stineman M, Zhang G, Kurichi JE, et al. Prognosis for functional deterioration and functional improvement in late life among community-dwelling older persons. PM R 2013;5:360-371. 2. Lunney JR, Lynn J, Foley DJ, Lipson S, Guralnik JM. Patterns of functional decline at the end of life. JAMA 2003;289:2387-2392. 3. Min L, Shekelle P. Wanted: A FRAME for staging functional decline in older adults. J Am Geriatr Soc 2012;60:2167-2168. PM&R
372
1934-1482/13/$36.00 Printed in U.S.A.
P.G. Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, 300 1st Avenue, Charlestown, MA 02129. Address correspondence to P.G.; e-mail: [email protected] Disclosure: nothing to disclose
© 2013 by the American Academy of Physical Medicine and Rehabilitation Vol. 5, 372-373, May 2013 http://dx.doi.org/10.1016/j.pmrj.2013.03.033
PM&R
4. Stineman MG, Xie D, Pan Q, Kurichi JE, Saliba D, Streim J. Activity of daily living staging, chronic health conditions, and perceived lack of home accessibility features for elderly people living in the community. J Am Geriatr Soc 2011;59:454-462. 5. Stineman MG, Ross RN, Fiedler R, Granger CV, Maislin G. Functional independence staging: Conceptual foundation, face
Vol. 5, Iss. 5, 2013
373
validity, and empirical derivation. Arch Phys Med Rehabil 2003; 84:29-37. 6. Gill TM, Williams CS, Richardson ED, Tinetti ME. Impairments in physical performance and cognitive status as predisposing factors for functional dependence among nondisabled older persons. J Gerontol A Biol Sci Med Sci 1996;51:M283-M288.
Prognosis for Functional Deterioration and Functional Improvement in Late Life Among Community-Dwelling Older Persons Paul Gerrard, MD The article by Stineman et al [1] in this issue of PM&R revisits the topic of the relationships among change in functional status, chronic disease burden, and mortality in older adults. We have witnessed many developments in the topic of functional assessment in older adults during the past decade, such as the characterizations of trajectories of decline approaching mortality [2] and the development of physical function staging tools by several different groups [3], including an activities of daily living (ADL) staging system developed previously by Stineman and her collaborators [4]. Stineman et al’s ADL staging system was credited as intellectual progress toward something referred to as the Functional Reserve Assessment Map for Elders (FRAME), an as-of-yet unidentified staging system that has been called for and that would characterize functional status in older adults, in a manner similar to that of the 4-stage heart failure classification, to help us better understand functional decline and to identify effective interventions [3]. The present study extends Stineman et al’s earlier work on functional staging by looking at transitions between ADL stages longitudinally in community-dwelling older adults during a 2-year time frame, and demonstrating among their analyses significant relationships between functional stage transitions and chronic disease burden. A useful FRAME staging system was described as an instrument that is clinically applicable, based on easily obtainable information relating to function, and able to be used to determine the relationship of various diseases to functional decline [3]. Stineman et al’s ADL staging system is no doubt based on functional data that are easily obtained, and the present study adds to this previous work, by showing that it also has clinical applicability as a prognostic tool and that it can be used to study the relationships of particular disease processes to functional decline, thus meeting the proposed criteria for a FRAME staging system. A remaining issue of interest is whether functional status in older adults should be staged by using other domains in addition to ADL performance, as Dr. Stineman et al have done for the inpatient rehabilitation population [5]. For example, cognitive status is an established predictor of functional dependence that is independent of physical functioning [6] and, as such, might warrant a staging domain distinct from the largely physical domain of ADL function. As accountable care organizations begin to populate the health care landscape, meaningful assessments of health status will become especially important for resource allocation decisions. To make these assessments efficiently, tools such as ADL staging will become increasingly important because of their abilities to distill a multidimensional trait such as functional status into meaningful strata.
REFERENCES 1. Stineman M, Zhang G, Kurichi JE, et al. Prognosis for functional deterioration and functional improvement in late life among community-dwelling older persons. PM R 2013;5:360-371. 2. Lunney JR, Lynn J, Foley DJ, Lipson S, Guralnik JM. Patterns of functional decline at the end of life. JAMA 2003;289:2387-2392. 3. Min L, Shekelle P. Wanted: A FRAME for staging functional decline in older adults. J Am Geriatr Soc 2012;60:2167-2168. PM&R
372
1934-1482/13/$36.00 Printed in U.S.A.
P.G. Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, 300 1st Avenue, Charlestown, MA 02129. Address correspondence to P.G.; e-mail: [email protected] Disclosure: nothing to disclose
© 2013 by the American Academy of Physical Medicine and Rehabilitation Vol. 5, 372-373, May 2013 http://dx.doi.org/10.1016/j.pmrj.2013.03.033
PM&R
4. Stineman MG, Xie D, Pan Q, Kurichi JE, Saliba D, Streim J. Activity of daily living staging, chronic health conditions, and perceived lack of home accessibility features for elderly people living in the community. J Am Geriatr Soc 2011;59:454-462. 5. Stineman MG, Ross RN, Fiedler R, Granger CV, Maislin G. Functional independence staging: Conceptual foundation, face
Vol. 5, Iss. 5, 2013
373
validity, and empirical derivation. Arch Phys Med Rehabil 2003; 84:29-37. 6. Gill TM, Williams CS, Richardson ED, Tinetti ME. Impairments in physical performance and cognitive status as predisposing factors for functional dependence among nondisabled older persons. J Gerontol A Biol Sci Med Sci 1996;51:M283-M288.