Findings from the current study suggest, on average, patients hospitalized for any reason experience an initial decline in life-space mobility as measured by the Life-Space Assessment. The group admitted for surgery had higher life-space scores prior to admission and recovered to at least their preadmission level of life-space within a year of hospitalization. This is in sharp contrast to participants admitted for a non-surgical reason. After adjusting for demographic covariates and ADL impairments, participants with a non-surgical admission had similar life-space scores prior to admission than those with a surgical admission, but failed to recover to baseline even after two years of follow-up despite having only moderate declines in life-space after hospitalization.
Participants admitted for a surgical procedure might be expected to have higher life-space as pre-operative functional status is a strong predictor of surgical outcomes and the severity of functional impairment can predict operative risk (20
). Pre-operative screening, which includes evaluation of function, helps determine the best candidates for elective surgical procedures (20
). The observed dramatic decline in life-space also is reasonable, given restrictions often imposed after an operation. Limitations of driving while healing from a sternotomy or total hip replacement are expected as part of the recovery process (21
The impact of a non-surgical hospitalization on life-space is concerning, particularly because participants, on average, never regained their previous life-space level. Reasons for this lack of improvement may include having significant comorbidities for which the expected course of illness is progressive decline. For example, patients with heart failure often have exacerbations and remissions, with a general trend toward disability due to their illness (23
). For older patients, common hospital-related issues may also contribute to life-space declines (5
). Deconditioning is common with 23–33% of older patients being limited to bed or chair during hospitalization (2
). Inadequate nutrition based on maintenance energy requirements (28
) and delirium may also contribute to life-space declines (30
The consequences of the observed life-space mobility declines are numerous and include abrupt life-style changes for patients and their families. A loss of independence and self-esteem may be experienced by older adults who now are dependent on equipment or the help of another person to leave the home (34
). This life-space decline may result in a decrease in the distance traveled from home, thus limiting participation in society (9
). Mobility is a core function that reflects the life-style of community-dwelling older adults and is an important predictor of morbidity and mortality (35
We report significant changes in life-space mobility after hospitalization. Some factors that impact life-space are not modifiable, such as acute illness severity. However, factors such as physical function and mental status are potential targets for intervention during hospitalization. Inouye et al. demonstrated a multifaceted intervention focused on six risk factors for delirium, including increasing mobility, reduced the incidence and duration of delirium in hospitalized older adults (36
). Acute Care for the Elderly (ACE) units, using patient-centered care, discharge planning, medication review and a specialized environment to maximize maintenance of ADL independence, have demonstrated reduced length of stay and hospital costs and an increased number of patients discharged to home (37
). The post-hospital period may also be an important time for interventions to improve function and mobility in recently hospitalized older adults. Post-hospitalization studies that included physical therapy for older adults noted improvement in instrumental ADLs and walking ability (39
). Thus, interventions are available to reduce adverse outcomes of hospitalization for older adults, potentially including the life-space mobility declines identified in the current study.
This study has a number of strengths including the racially balanced, population-based sample of community-dwelling older adults prospectively followed for over four years. The use of life-space, which is easily administered and detects both increases and decreases in community mobility and participation in society over time, is another strength. Assessments of life-space mobility were not captured immediately before and after hospitalization, however the use of longitudinal growth models allowed us to approximate these trajectories using the available data points from our biannual assessments. For the 211 hospitalized participants, life-space assessments occurred at some point during the six-months before and after the incident hospitalization. These time points, which occurred from 1 to 180 days before and after the incident hospitalization, were used to create the models presented. Some hospitalizations may have been missed due to failure to recall all hospitalizations. However, participants or their proxies would likely remember a hospitalization within 6 months as it is usually a major event. Using self-reported reasons for hospitalization limited our ability to determine emergent versus non-emergent surgeries, a difference that could influence life-space mobility recovery. Because admission reasons were self-reported, some misclassification was also possible. To address this concern categorization was limited to major surgical and non-surgical with the expectation that participants would likely remember any major surgical operations. Any other reason for hospitalization was then categorized as non-surgical. Data regarding use of rehabilitation services were not collected, which could impact on recovery of life-space after hospitalization.
We observed a high prevalence of life-space mobility declines after all hospitalizations. While participants with surgical hospitalizations made significant recoveries of their life-space mobility over time, those with non-surgical hospitalizations did not achieve this improvement to pre-hospital life-space status even after up to two years of follow-up. By using a global definition of function, as measured by the UAB Study of Aging Life-Space Assessment, we have demonstrated a significant proportion of patients are impacted by hospitalization and many never recover. This finding argues for further study into the processes of hospital care and development of interventions to lessen the negative impact of hospitalization on life-space mobility.