Editor's note: Commentary based on Dharmarajan K, Han L, Gahbauer EA, Leo-Summers LS, Gill TM. Disability and Recovery After Hospitalization for Medical Illness Among Community-Living Older Persons: A Prospective Cohort Study. J Am Geriatr Soc 2020;68:486-95.

Rationale for Study:¹
With respect to basic, instrumental, and mobility activity in the post-hospitalization period:
1) What is the prevalence of disability monthly for the first 6 months?
2) What is the disability incidence 1 month after hospitalization?
3) What is the recovery time from incident disability during months 2 to 6 after hospitalization?

Funding:
This study was funded by grant R01AG17560 from the National Institute on Aging (NIA).

Methods:
The authors studied disability and recovery trends among patients hospitalized for an acute noncritical medical illness from the Precipitating Events Project (PEP) who were discharged to a nursing facility or home. The authors assessed disability monthly by telephone interview, defined for each basic (bathing, dressing, walking, transferring), instrumental (shopping, housework, meal preparation, taking medications, managing finances), and mobility activity (walking a quarter mile, climbing flight of stairs, lifting/carrying 10 pounds, driving) if help was needed to perform the activity.

Study Design: Prospective Cohort Study

Cohort: Precipitating Events Project (PEP) - 754 community-living persons, aged 70 years or older, who required no assistance at the time of study enrollment.

Exposure: Acute non-critical medical illness leading to new onset disability.

Outcome(s): Prevalence and incidence of disability (basic, instrumental, and mobility).

Statistical Analysis:
Baseline characteristics of all hospitalized patients were reported. The prevalence of disability in each category in the month before hospitalization and each of the 6 months after hospitalization, and the proportion of participants with incident disability in the month after hospitalization were calculated. Kaplan-Meier survival curves were used to evaluate time to recovery from an incident disability, with follow-up starting two months after hospitalization. The proportion of participants with an incident disability who were no longer disabled in that activity 6 months after hospitalization was calculated.

Results:
The final study population consisted of 515 participants (mean age 82.7 years, 65.5% female, and 88.9% white), with a high prevalence of geriatric conditions and low physical activity (50.1%) at baseline. The prevalence of disability was highest 1 month after hospitalization, particularly in areas of self-care (bathing, dressing, meal preparation, taking medications) and mobility (walking a quarter mile, climbing stairs), and remained common at month 6. Incident disability in the first month after hospitalization was common, particularly among community living adults. For example, 30.6% of participants had a new disability in bathing, 41.6% had a new disability in meal preparation, and 43.0% had a new disability walking a quarter mile. Kaplan-Meier analysis showed that the mean time to recovery from an incident disability varied between 1.3 and 2.0 months. However, recovery was often incomplete even 6 months after hospital discharge, particularly among those discharged to community living settings. The proportion of participants nondisabled from their incident disability at 6 months was only 65.4% for bathing, 57.8% for taking medications, and 76.1% for walking a quarter mile among those discharged to a nursing facility, and 79.3%, 78.0% and 85% respectively for those initially discharged home.

Limitations of study: Measures of disability were self-reported, thus not objective. Due to differing characteristics among participant with each incident disability, statistical comparisons of recovery were not possible. Participants hospitalized for surgical or severe medical illness requiring intensive care unit stay were excluded, so the results are applicable only to a specific cohort.

Geriatric Cardiology Perspective:
In this community-based study of elderly participants, disability was common and often novel, irrespective of whether patients were discharged home or to a nursing facility. In particular, incident disability in basic activities including bathing, transferring to chair, and walking across a room is common and can persist 6 months after an event.

These persistent disabilities can contribute to difficulty in accessing ambulatory level health care, attention to self-health, and may ultimately contribute to prolonged recovery. These findings may support the need for resource allocation to the delivery of home care (i.e. laboratory services, nursing-care, utilization of tele-health) and therapeutic ancillary health services for extended time beyond the current standard post-hospitalization, or post-acute care period.

Although testing and further research are needed, perhaps resistance training, nutritional optimization, and cognitive rehabilitation may improve physical functioning while hospitalized, serving as platforms to reduce future disability. The high prevalence of baseline diminished physical activity, physical capacity (hand grip strength), obesity, and geriatric syndromes prior to incident mobility disabilities among these participants also suggests the need for potentially augmenting preventive interventions in the ambulatory setting prior to hospitalization.

References

1. Dharmarajan K, Han L, Gahbauer EA, Leo-Summers LS, Gill TM. Disability and Recovery After Hospitalization for Medical Illness Among Community-Living Older Persons: A Prospective Cohort Study. J Am Geriatr Soc 2020;68:486-95.

Clinical Topics: Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Geriatric Cardiology, Prevention, Sports and Exercise Cardiology, Exercise

Keywords: Geriatrics, Patient Discharge, Kaplan-Meier Estimate, Subacute Care, Prevalence, Self Report, Resistance Training, Self Care, National Institute on Aging (U.S.), Prospective Studies, Follow-Up Studies, Hospitalization

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