The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 58:M94 (2003)
© 2003 The Gerontological Society of America
Letters to the Editor: Acute Illnesses, ADL Decline, and Hospitalization
Renzo Rozzini,
Tony Sabatini and
Marco Trabucchi
Medical Unit for the Acute Care of the Elderly (Poliambulanza Hospital) and Geriatric Research Group via Romanino 1 25122 Brescia, Italy
To the Editor:
The effect of acute disease and related hospitalization on Activities of Daily Living (ADL) in the elderly is one of the most relevant problems in geriatric care. We read with interest the recent articles on acute and chronic illness and ADL decline and their relationship to frailty (1,2,3), and we would like to compare their data with our own data on a population of elderly patients consecutively admitted to our Acute Care for the Elderly (ACE) Medical Unit at Poliambulanza Hospital, Brescia, during the period between January and December 2000.
In order to avoid the ceiling effect, for the purpose of the study, patients with a Barthel Index score (detected 2 weeks before admission) higher than 90 were excluded from the analysis. There were 531 patients (length of stay 7.0 ± 3.2). As in the population analyzed by Sands and colleagues (1), our patients were very old (mean age 82.1 ± 7.2) and frail (Barthel Index score on admission 56.4 ± 28.3, Mini-Mental State Examination [MMSE] 19.5 ± 7.9, Charlson Index 7.6 ± 2.5, serum albumin 3.8 ± 0.6 g/dL).
The changes in functional status (Barthel Index) as detected 2 weeks before the hospitalization, at admission, and on discharge are reported in Table 1. The patients have been stratified into three groups accordingly to the Barthel Index as detected 2 weeks before the hospitalization and as detected at admission.
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Table 1. Changes in Patients' Ability to Perform ADLs, Evaluated by the Barthel Index, as Detected 2 Weeks Before Admission, on Admission and at Discharge According to the Barthel Index Score Before the Acute Event and on Admission
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Our data allow us to comment as follows:
- Acute diseases induce a loss of function that is less pronounced in most disabled persons (floor effect?). We agree with Sands and colleagues (1) that this functional decline "does not follow a long course of progressive deterioration" but it is strictly related to the acute events.
- Hospitalization allows the partial recovery of functions lost through the course of acute illnesses (disease–disability link) and at the same time avoids the risk of hospital-induced immobilization.
- The ACE unit model is effective in improving functional outcome in frail elderly patients (4–6) even after a short period of hospitalization. In fact the most relevant effect is obtained in patients with a Barthel Index lower than 20 on admission.
- We advocate the ability of geriatric medicine to integrate the traditional organ-oriented interventions with specific procedures directed to maximize functional status. We believe that this is the only approach that can produce significant clinical outcomes in elderly patients.
Further, these data support the role of geriatricians in the care of chronic diseases as advocated by Kane (7).
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REFERENCES
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- Sands LP, Yaffe K, Lui L, Stewart A, Eng C, Covinsky K. The effects of acute illness on ADL decline over 1 year in frail older adults with and without cognitive impairment. J Gerontol Med Sci. 2002;57A:M449-M454.[Abstract/Free Full Text]
- Dolan MM, Hawkes WG, Zimmerman SI, et al. Delirium on hospital admission in aged hip fracture patients: prediction of mortality and 2-year functional outcomes. J Gerontol Med Sci. 2000;55A:M527-M534.[Abstract/Free Full Text]
- Buttar A, Blaum C, Fries B. Clinical characteristics and six-month outcomes of nursing home residents with low activities of daily living dependency. J Gerontol Med Sci. 2001;56A:M292-M297.[Abstract/Free Full Text]
- Bortz WM. A conceptual framework of frailty: a review. J Gerontol Med Sci. 2002;57A:M283-M288.[Abstract/Free Full Text]
- Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol Med Sci. 2001;56A:M146-M156.
- Gillick M. Pinning down frailty. J Gerontol Med Sci. 2001;56A:M134-M135.[Free Full Text]
- Kane RL. Future history of geriatrics: geriatrics at the crossroads. J Gerontol Med Sci. 2002;57A:M803-M805.[Free Full Text]
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