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The Effects of Acute Illness on ADL Decline Over 1 Year in Frail Older Adults With and Without Cognitive Impairment

^a Center on Aging, Division of Geriatrics,
^b Departments of Medicine, Division of Geriatrics,
^c Psychiatry, University of California, San Francisco
^d Neurology, University of California, San Francisco
^e Epidemiology and Biostatistics, University of California, San Francisco
^f Institute for Health and Aging, University of California, San Francisco
^g Veterans Affairs Medical Center, San Francisco, California

Laura P. Sands, Center on Aging, Department of Medicine, Division of Geriatrics, University of California, San Francisco, 3333 California Street, Box 1265, San Francisco, CA 94143-1265 E-mail: lsands{at}medicine.ucsf.edu.

	Abstract

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Background. Acute illness may lead to long-term losses in older adults' ability to independently perform activities of daily living (ADLs). The magnitude of these losses may differ for patients with and without cognitive impairment. These relationships have not been described for the frailest of older adults whose high rates of acute illness and cognitive impairment put them at the greatest risk for loss of ADL functioning.

Methods. We conducted a prospective study of 2593 patients enrolled in a nationwide medical and psychosocial program for frail, community-living, nursing home-eligible patients. We determined the independent and interactive effects of baseline cognitive impairment and admission for an acute illness on change in ADL functioning over 1 year.

Results. ADL decline over 1 year occurred in 53% of cognitively impaired patients who were admitted for an acute illness, 38% of cognitively impaired patients who were not admitted for an acute illness, 42% of noncognitively impaired patients who were admitted for an acute illness, and 25% of noncognitively impaired patients who were not admitted for an acute illness (p < .001). The amount of additional decline in ADLs associated with an admission for an acute illness was similar between patients with and without cognitive impairment (-.85 vs -.74; p for interaction = .86). Among patients who were admitted for an acute illness, significant decline in ADL functioning occurred only in the quarter surrounding the acute illness with no evidence of recovery in the months after the acute illness episode.

Conclusions. Among frail older adults, loss of ADL functioning over 1 year is independently associated with both acute admission for an acute illness and cognitive impairment. Frail elders, especially those with cognitive impairment, are in need of interventions that reduce the long-term functional consequences of acute illness.

OLDER adults who lose ability to perform activities of daily living (ADLs) are at risk for decreased quality of life, institutionalization, and death ^(1)(2)(3). Studies have defined the course and risks of functional decline for older adults in general ^{(4)(5)(6)(7)(8)}, but they have not focused on frail older adults whose high rates of chronic and acute illness and already low levels of functioning put them at high risk for losing additional ADL functioning and needing institutional care ⁽⁷⁾. Studying the course and risks of ADL decline for the frailest of older adults permits the identification of conditions and events that take place just prior to the loss of ADL functioning and institutionalization in older adults.

For frail older adults, loss of ADL functioning is likely the result of deleterious acute events that precipitate a loss in functioning, combined with the deteriorating effects of chronic conditions that predispose older adults to lose ADL functioning ⁽⁹⁾. For older adults in general, acute illness that requires hospital care is known to precipitate sudden and often lasting ADL decline ^{(10)(11)(12)(13)}, and chronic cognitive impairment is known to cause insidious, irreversible loss of ADL functioning ^{(14)(15)(16)(17)(18)}. Prior studies have also shown that cognitively impaired older adults have worse functional outcomes after an acute hospitalization ^{(9)(11)(12)(19)(20)(21)}. While rates of admission for acute illness and cognitive impairment are highest for frail older adults, prior studies have not focused on their independent and interactive contribution to ADL decline over 1 year in the frailest elders. The design of interventions to forestall further functional decline and delay institutionalization requires an understanding of precipitating and predisposing causes that lead to functional decline in frail older adults.

The goals of this prospective study were to examine the independent and interactive effects of admission for an acute illness and cognitive impairment on the magnitude and course of ADL decline over 1 year in frail older adults. We studied 2593 patients enrolled in the Program of All-inclusive Care for the Elderly (PACE), a medical and psychosocial program for older adults who prefer to reside in the community. Because frailty and nursing home eligibility are requirements for PACE entry, PACE is an excellent setting in which to better understand the causes and course of ADL decline in frail older adults who are most proximal to requiring institutional care.

	Methods

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Subjects
We studied PACE patients who were enrolled between January 1, 1992 and December 31, 1996. We analyzed data from 11 PACE demonstration sites including San Francisco, Columbia (South Carolina), Denver, East Boston, El Paso, Milwaukee, Detroit, Oakland, Portland (Oregon), Rochester, and Sacramento. Data from the Bronx site were not analyzed because there were significantly more missing data from this site.

During this period, 3698 patients were enrolled in the above 11 PACE sites. Among them, 3108 patients had complete baseline health assessments and were enrolled in PACE for at least 1 year. We excluded 497 without a follow-up health assessment within 9 to 15 months of their baseline assessment due to death or loss to follow-up. Finally, we excluded 18 patients who were missing functional data during the 9- to 15-month follow-up assessment. The resulting analytic sample included 2593 PACE patients.

Data Collection and Measurements
We analyzed data from DataPACE, a database that includes clinical, functional, social, and resource use data collected upon PACE enrollment and quarterly thereafter. Baseline data came from the patients' enrollment health assessment. The 1-year follow-up data came from the health assessment interview that occurred nearest to 12 months after the baseline interview within a window of 9–15 months. Demographic variables were recorded during the patients' enrollment interview.

During the enrollment health assessment and during subsequent quarterly health assessments, nurses determined patients' level of independence in performing five ADLs: bathing, dressing, toileting, eating, and transferring. For all patients, nurses rated patients as independent (able to do the activity without help), partially dependent (requiring some assistance), or completely dependent (needing help for the entire activity) in their ability to perform each ADL. Nurse ratings were based on direct observation, questioning of patients, and speaking with family members and caregivers. These assessments occurred in the PACE clinic, though in some cases they were completed in the patient's home if the patient was completely homebound. We created a summary score for the activities with values ranging from 0 (completely dependent in all activities) to 10 (completely independent in all activities) by giving two points for each completely independent ADL, one for each partially dependent ADL, and 0 for each completely dependent ADL.

Cognitive status was assessed during the baseline interview with the 10-item Short Portable Mental Status Questionnaire. Scores range from 0 errors (no impairment) to 10 errors (severe impairment). We considered patients with a score of 6 or greater to have moderate to severe cognitive impairment, based on previously established norms ⁽²²⁾. Throughout this report, we refer to patients with a score of 6 or greater as "cognitively impaired" patients.

Our operational definition of acute illness was illness of sufficient severity to require admission to a care setting outside of the patient's home. Admission for acute illness was recorded from monthly utilization reports. PACE uses a variety of settings outside the patient's home to provide care for acutely ill patients including hospitals, nursing homes, and transitional housing. Some sites regularly used nursing homes or transitional housing for the care of their acutely ill patients. Thus, to capture the complete spectrum of acute illness from all sites, we defined admission for an acute illness as a new admission to any of these facilities for the purpose of providing care for acute illness that resulted in a length of stay of less than 1 month. We limited the length of stay to 30 days to avoid potential bias that could occur by including long-term transfers to any of these facilities.

Physicians recorded presence or absence of comorbid conditions based on examination and assessment during the enrollment health assessment interviews. We included baseline data for nine conditions: malignant neoplasm, diabetes, depression, cerebrovascular disease, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, arthritis, and osteoporosis.

To assess the timing of ADL decline in patients admitted for acute illness, we created three intervals based on the timing of the admission. The first interval examined ADL change prior to the first admission. This interval included the baseline health assessment and the first quarterly health assessment. Patients admitted prior to the first quarterly health assessment did not contribute data to this interval. The second interval examined change in ADL during the quarter surrounding the patient's admission for an acute illness. This interval included the quarterly health assessment prior to the first admission for an acute illness and the quarterly health assessment immediately following the last admission for an acute illness; patients were included in this interval only if these assessments occurred within 3–6 months of each other. The third interval examined ADL change following the last admission. Only patients with two health assessments following the last admission were included in this interval. The number of patients included in each of these three intervals differed depending on the timing of patients' first and last admission for acute illness. Patients contributed data to between one and three of these intervals.

Statistical Methods
The main dependent variable was change in ability to perform ADLs over 1 year. Change was defined both as categorical change and the magnitude of change. We distinguished three levels of categorical change: (i) patients whose functioning was "better" had higher ADL scores at follow-up compared to baseline, (ii) patients who were the "same" did not change in their ADL score between baseline and a year later, and (iii) patients who were "worse" declined in their ADL score from baseline to follow-up. We determined the magnitude of absolute change over 1 year by subtracting the baseline ADL score from the follow-up ADL score 1 year later. A positive score indicates improvement.

We stratified the sample according to whether or not the patient was cognitively impaired at baseline and whether or not the patient had an admission for an acute illness. This double stratification allowed examination of the independent effects of cognitive impairment and admission for an acute illness on functional decline.

To compare frequency of change (better, same, or worse ADL function) between each of the four groups, we computed a Mantel-Haenzel test for trend and chi-square tests for pairwise comparisons. The independent odds of decline for each group were calculated using logistic regression analyses that controlled for baseline characteristics (age, education, baseline functioning, and the nine baseline comorbid conditions). Patients without cognitive impairment who were not hospitalized were the reference group.

To compare the magnitude of change in ADL function between the four groups, we ran a random regression model with the dependent variable being absolute change from the first health assessment to the last health assessment during the year. The independent variables indicated whether or not the patient was cognitively impaired at baseline and whether or not the patient had experienced an admission for an acute illness during the year. Covariates were baseline functioning, age, education, and the nine comorbid conditions. To assess whether patients with cognitive impairment at baseline who were admitted for an acute illness had significantly greater functional decline over 1 year than would be expected from the independent effects of cognitive impairment and acute illness, we included an interaction term in the random regression model.

To assess the timing of ADL decline for patients who were admitted for an acute illness, we ran random regression models for each of the three intervals described above. The dependent variables in these models were absolute change in functioning from the health assessment at the beginning of the interval to the health assessment at the end of the quarterly interval. The independent variable was baseline cognitive impairment, and the covariates were baseline functioning, age, education, and the nine comorbid conditions listed above.

	Results

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Cognitively impaired PACE patients were significantly older and less educated than patients with mild to no cognitive impairment (Table 1 ). Scores for baseline ADL functioning were significantly lower for patients with cognitive impairment. In contrast, patients with cognitive impairment had lower rates of comorbidity compared with patients with mild to no cognitive impairment.

View larger version (23K): [in this window] [in a new window]   Figure 1. Percentage of patients who changed in activity of daily living functioning over 1 year.

View larger version (16K): [in this window] [in a new window]   Figure 2. Magnitude of change in activity of daily living (ADL) functioning over 1 year. ADL scores are adjusted for nine comorbid conditions, education, age, and baseline level of functioning.

Among patients admitted for an acute illness, significant decline in ADL functioning occurred only during the quarterly health assessment interval that included the admission for an acute illness (Fig. 3). During that time (panel B), significant decline in functioning occurred for patients without cognitive impairment (p < .001) and patients with cognitive impairment (p < .001). In contrast, there was little evidence of decline in the quarterly interval preceding the acute illness that required care outside of the home. Significant change in functioning was not detected for either group in the interval after the last acute illness that required care outside of the home, suggesting that, overall, patients did not improve after discharge for the acute illness.

View larger version (18K): [in this window] [in a new window]   Figure 3. Cognitive impairment and quarterly change in functioning before, during, and after hospitalization. Activity of daily living (ADL) scores are adjusted for nine comorbid conditions, education, age, and baseline level of functioning. A: n for patients without cognitive impairment at baseline = 254; n for patients with cognitive impairment at baseline = 158. B: n for patients without cognitive impairment at baseline = 423; n for patients with cognitive impairment at baseline = 250. C: n for patients without cognitive impairment at baseline = 152; n for patients with cognitive impairment at baseline = 81. QHA = quarterly health assessment; NS = not significant.

	Discussion

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We determined that functional loss associated with admission for an acute illness occurs only during the months surrounding admission for the acute illness for patients with and without cognitive impairment. This suggests that functional decline in older adults who are admitted for an acute illness does not follow a long course of progressive deterioration that eventually leads to changes in health that are marked by acute illness and hospitalization.

Prior studies have reported that cognitive impairment is associated with poor functional outcomes following hospitalization ^(12)(19)(21), but these studies did not focus on the frailest elders, nor could these studies determine whether preexisting cognitive impairment was associated with poorer functional outcomes after hospitalization because they assessed patients' cognitive status only at hospital admission. Thus, it is unclear whether the relationship between cognitive impairment and ADL decline found in prior studies was due to concomitant losses in cognitive and ADL functioning that were associated with the acute illness that led to the hospitalization. One study did demonstrate that the combination of prior cognitive impairment, advanced age, and poor gait functioning substantially increases the risk of losing functional independence after hospitalization ⁽⁹⁾, though they did not specify the unique contribution of prior cognitive impairment. Our study clarified that frail older adults with prior cognitive impairment are at significant risk for loss of functioning over 1 year, and their risk of losing ADL functioning is almost doubled if they are admitted for an acute illness.

Prior research suggests that cognitive impairment may worsen the outcomes of acute illness by compromising compensatory mechanisms that are needed to recover from acute illnesses ^(23)(24). However, we did not find support for this hypothesis. It is possible that two characteristics of our study reduced our ability to detect a significant interaction between cognitive impairment and acute illness on ADL loss over 1 year. First, our 1-year interval may have been too broad to detect multiplicatively worse outcomes occurring immediately after the admission for acute illness for patients with cognitive impairment. Second, the significantly poorer health status of patients without cognitive impairment may have obscured differential patterns of functional change between patients with and without cognitive impairment. Even though we statistically controlled for nine baseline comorbid conditions in the multivariate models, we could not control for the severity of these and other chronic conditions. Further research is needed to understand the relative contributions of prior health status and cognitive impairment on long-term functional outcomes of frail older adults who are admitted for an acute illness.

The strengths of this study lie in the unique aspects of the PACE database. It provides prospective data on the health and functioning of thousands of frail community-residing older adults who are eligible for nursing home entry. The patients included in the database live throughout the United States and represent more than five ethnicities. The quarterly assessments provide longitudinal data to study how acute and chronic illness lead to subsequent change in functioning and the timing by which this change in functioning occurred.

This study also has several limitations. First, while we knew whether patients had a diagnosis of dementia and their score on a 10-item mental status screen, we did not know the etiology of patients' cognitive impairment. Without this information, we could not test whether the lack of an interaction between hospitalization and prior impairment was consistent for cognitive impairment due to degenerative (e.g., Alzheimer's disease) or vascular (e.g., multiinfarct dementia) causes. A second limitation of this study is potential bias arising from the greater use of family members to obtain ADL data for patients with cognitive impairment. However, it is unlikely that this bias seriously affected results because prior studies have shown that surrogate bias is lowest for directly observable measures such as ADL functioning ^(25)(26), and nurse ratings of patients' functioning included information derived from the nurses' direct observations of patients' functioning. Also, because our primary outcome was change in functioning, such biases would have only affected our results if they changed over time. A third limitation is that our operational definition of acute illness may have included events that could not be characterized as an acute illness. We addressed this by rerunning the analyses including only acute events that occurred in the hospital and found the results to be nearly identical.

Despite these limitations, this study increased our understanding of the course and risks for functional loss in frail older adults who are on the cusp of needing institutional care. Our study suggests that those who design interventions to forestall functional decline and institutionalization in the frailest elders should consider the effects of cognitive impairment and acute illness on functional outcomes. In the absence of acute illness, interventions that have been proven to improve functioning in frail older adults may be effective in reducing ADL decline over 1 year ^(27)(28)(29). Cognitively impaired older adults may benefit from modified versions of these interventions. In the presence of acute illness, the most effective interventions may be those that reduce barriers to the recovery of functional loss that is associated with the acute illness ⁽²⁴⁾. Examples include hospital-based interventions designed to improve the functional outcomes for acutely ill older patients ^(30)(31). Frail older adults like those in PACE have already experienced losses in functioning, and even modest additional functional losses could precipitate the need for institutional care. The implementation of appropriate interventions to prevent further functional decline and restore acute losses in functioning would likely reduce rates of institutionalization and improve quality of life in frail older adults.

	Acknowledgments

 
The John A. Hartford Foundation in New York City funded the creation of the dataset and the software program for data entry and reporting.

The Health Care Financing Administration funded the management of the dataset from 1992–1998 through a contract with On Lok, Inc., in San Francisco.

Dr. Covinsky was supported in part by an independent investigator award from the Agency for Health Care Research and Quality K02HS00006-01 and is a Paul Beeson Faculty Scholar in Aging Research. Dr. Yaffe was supported by a grant from the National Institutes of Health K23-AG00888 and is a Paul Beeson Scholar in Aging Research.

Received October 19, 2001

Accepted January 16, 2002

	References

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