Our results demonstrate that decline in self-care ADL function associated with hospitalization for medical illnesses is often a sentinel and highly-morbid event for elders. The prognosis for elders discharged with new or additional disability in self-care ADL is extremely poor, with only 30% returning to their pre-admission level of self-care ADL functioning by one year. Among those discharged with new or additional disability in self-care ADL, functional recovery by one month is a predictor of one-year outcomes. However, in some cases, time to recovery was prolonged as 38% of those who were at baseline function at one year required more than one month for recovery.
Long-term information on elders’ recovery of function after hospitalization is critically important because large numbers of elders are hospitalized for medical illnesses on an annual basis, and functional decline associated with hospitalization is very common.1-5, 8, 29
Previous reports have documented functional outcomes in hospitalized elders up through 3 months.4, 8, 9, 13, 14
This is one of the first reports to document that the long-term prognosis of hospital-associated new or additional disability in self-care ADL is poor and substantially worse than that observed among community-dwelling elders with disability arising from a broad range of causes.10, 18
Rather, our results suggest that the prognosis for hospital-associated disability in self-care ADL is similar to that reported for other catastrophic conditions such as hip fracture and stroke.30, 31
The processes underlying these long-term outcomes are likely to be complex and highly dynamic.10, 32
Our results have important implications for hospital physicians and providers because they suggest that hospitalized elders may have dramatically higher care needs than before their incident hospitalization. New or additional disabilities in self-care ADL function acquired by the time of hospital discharge have important implications for the patient’s ability to live at home and for their needs for home care services. In addition, the demands on caregivers will markedly increase. As recovery is sometimes prolonged, and some patients who initially recover subsequently decline, our results provide evidence that post-hospitalization functional decline is a chronic, dynamic, long-term process, likely necessitating both acute and chronic services.
The timing, structure, duration and intensity of rehabilitation in acute rehabilitation facilities, long-term care hospitals, skilled nursing facilities, outpatient sites, and home health agencies may not be well suited to the needs of patients with hospital-associated functional decline, whose needs may be long term and chronic. The prospective payment system and diagnosis related groups for acute hospitals and the post-acute sector led to shorter hospital lengths of stay with subsequent increases in post-acute care health utilization and costs during the 1990s.19, 20, 33, 34
While the numbers of patients with medical illnesses receiving post-acute physical, occupational, or speech services has increased in skilled nursing facilities, rehabilitation hospitals, and long-term care hospitals, the amount of rehabilitation received by patients has decreased in some settings and remains of short duration (<1 month).19, 20, 35-37
Little is known about the functional consequences of these utilization changes to older medical patients, or the best way to cost-effectively deliver high quality care that maximizes functional outcomes.
Few elders hospitalized with medical conditions receive acute inpatient rehabilitation.3, 38, 39
The rates of patients with stroke, chronic obstructive pulmonary disease, pneumonia, congestive heart failure, hip fracture receiving inpatient post acute rehabilitation services upon discharge ranged from 0.2%-13% in 1996-1998, with the highest rates observed for stroke and hip fracture.40
Stroke and hip fracture patients have better 1-year functional outcomes if they receive post-acute care, with the best outcomes seen in those discharged to rehabilitation facilities.34
The timing, duration and intensity of therapy are related to functional gains.41, 42
Less is known about patients with functional decline associated with medical illnesses, but therapy intensity is related to gains in mobility, ADL, and executive control among patients with cardiovascular and pulmonary conditions in skilled nursing facilities and increases the likelihood of being discharged to the community.22, 43
Current rehabilitative utilization patterns suggest that many medical patients with functional decline are not receiving the most aggressive short-term intervention available. Possible explanations include inability to meet functional requirements or the requirement that 75% of admissions to inpatient rehabilitation facilities be for specific categorical diagnoses.19, 20, 35-37
It is not known who with medical illness is most likely to benefit from acute rehabilitation, or whether care through home care, skilled nursing facilities, or rehabilitation hospitals would be most likely to improve outcomes.44, 45
Average duration of rehabilitation in all these post-acute sites is relatively short given that 38% of older patients who recover in one year require more than one month to do so. Based on our results, aggressive rehabilitation may be indicated in the first month; but since substantial functional change continues to occur in subsequent months, in many cases it may be important to target longer-term rehabilitation to increase recovery rates and maintain recovery when it occurs.10
Restorative care for older persons receiving home care after acute illness and “prehabilitation” for frail elders, who may have frequent hospitalizations, may be opportunities to maximize functional outcomes.46, 47
Appropriate targeting of older patients for rehabilitation interventions is a critical issue, and current aggressive rehabilitation strategies may be difficult among patients residing in nursing homes or with severe dementia. While our results do not identify which patients are most likely to benefit from interventions, it does suggest that older age, cardiovascular disease, dementia, cancer, lower albumin and prior IADL disability predict failure to recover. It is important that future research also try to distinguish between patients who have the potential for reversibility, and patients for whom this functional decline indicates that the patient is at the end of their life. The high one-year mortality rate among patients with hospital-associated functional decline should prompt consideration of palliative needs. Among patients who are at the end of their life, aggressive palliative interventions focused on symptom management and caregiver support may be more beneficial than interventions aimed at restoring function. Often, it may be appropriate to consider palliative care in tandem with rehabilitative efforts.