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Long-term Care

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Researchers examine functional decline among the frail elderly

Physiological markers of illness, such as laboratory values and vital signs, generally improve and often normalize during hospitalization among elderly patients. However, functional measures often fail to improve and frequently worsen. Similarly, frail older people, whose end-of-life course is often complicated by multiple chronic diseases, may steadily decline in function. The following two studies, which were supported in part by the Agency for Healthcare Research and Quality (K02 HS00006), and led by Kenneth E. Covinsky, M.D., M.P.H., of the San Francisco VA Medical Center, examined functional decline among frail older people.

Covinsky, K.E., Palmer, R.M., Fortinsky, R.H., and others (2003, April). "Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: Increased vulnerability with age." Journal of the American Geriatrics Association 51, pp. 451-458.

This study highlights the need for clinicians to closely monitor the functional status of hospitalized seniors, especially the oldest patients. More than half of elderly patients hospitalized for medical illnesses find it difficult to carry out activities of daily living (ADLs) such as bathing and dressing. In this study, by the time of discharge, more than one-third of elderly patients had worse ADL function than they did 2 weeks before hospital admission. This rate of functional decline had a striking relationship with age, with declining ADL functioning exceeding 50 percent among patients aged 85 and older. The oldest frail elderly were less likely to recover function lost before hospital admission and were more likely to develop new functional deficits during hospitalization.

More studies are needed to see if hospital functional decline can be reversed through rehabilitation and other interventions, suggest the researchers. For this study, they prospectively examined functional outcomes among 2,293 patients aged 70 and older. They interviewed the patients about their independence in five ADLs: bathing; dressing; eating; transferring, for example, from bed to chair; and toileting, 2 weeks before admission (baseline), at admission, and at discharge.

Overall, 35 percent of patients declined in their ability to perform these daily tasks between baseline and hospital discharge. The frequency of ADL decline between baseline and discharge varied markedly with age (23, 28, 38, 50, and 63 percent in patients aged 70-74, 75-79, 80-84, 85-89, and 90 and older, respectively). Among patients who declined in functioning before admission, those aged 90 years and older were twice as likely to fail to recover ADL function during hospitalization as those aged 70-74. Patients aged 90 and older who did not decline before admission were over three times as likely to develop new losses of ADL function during hospitalization as those aged 70-74.

Covinsky, K.E., Eng, C., Lui, L., and others (2003, April). "The last 2 years of life: Functional trajectories of frail older people." Journal of the American Geriatrics Society 51, pp. 492-498.

According to this study, elderly patients with advanced frailty experience a slowly progressive functional decline during the year before death, with only a slight acceleration in functional loss as death approaches. There usually are no abrupt changes in function that signal the onset of a terminal phase among the frail elderly. Thus, end-of-life care systems such as the Medicare hospice benefit, are poorly suited to older people dying with progressive frailty. The Medicare hospice benefit requires physicians to certify that patients have an estimated prognosis of less than 6 months and, in practice, often requires patients to make an either/or choice between life-prolonging or comfort care.

Such a benefit is particularly suited to patients whose course clearly demarcates a point in time when death is nearing, for example, patients with lung cancer. It is less well suited for the majority of older people, whose cause of death is often related to the insidious progression of multiple illnesses and dementia, note the researchers. They examined the functional trajectories over the last 2 years of life of 917 patients who died while enrolled in the Program of All-inclusive Care (PACE) for the elderly. They collected data at PACE entry and every 3 months thereafter on the degree of dependence in bathing, eating, and walking and the degree of incontinence.

Rates of functional impairment were high in patients without cognitive impairment during the 3 months prior to death (93 percent for bathing, 40 percent for eating, 69 percent for mobility, and 49 percent for continence). Cognitively impaired patients were more likely than non-cognitively impaired patients to have the maximal level of dependence in the 0-3-month window before death (for example, 56 vs. 30 percent for mobility) and were more likely to decline in the 2 years before death (56 vs. 36 percent for mobility).

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