Natural History of Functional Decline 1 Year After Hospital Discharge in Nonagenarian Patients

To the Editor: The use of hospital care increases significantly with age, especially by extremely elderly patients such as nonagenarians. 1,2 Almost one-third of older adults hospitalized for acute medical illness decline in their ability to perform basic activities of daily living (ADLs) at discharge. 3 Rate of functional decline may be higher in oldold patients, 4 and this decline in ADLs related to hospitalization may persist 3 months later and in many patients 1 year after discharge. 2,5 We investigated the consequences of hospitalization on the nonagenarian patient’s functional capacity and the requirements of institutionalization in the first year after hospital discharge. A prospective longitudinal study was performed, focusing on 300 consecutive nonagenarian patients admitted to the hospital from the emergency department of two university hospitals during 2000. Exclusion criteria were hospital discharge (n 63) or death (n 27) in the first 72 hours of admission, patients admitted because of palliative care treatment (n 11), patients completely impaired in all ADLs (n 10), or patients with a cognitive or communication impairment in the absence of a caregiver (n 7). The admission assessment included baseline demographic information including current living situation. Functional status was assessed using the Barthel Index (BI). 6 Charlson Comorbidity Score (CCS) was used to measure comorbidity. 7 The office of Population Censuses and Surveys was contacted when the patient was not found to confirm their status. The results were analyzed using conventional descriptive statistics (chi-square test, paired t test, and one-way analysis of variance). All statistical tests were two-sided, with P . 05 as the criterion to indicate statistical significance. One hundred eighty-two patients were included; 123 were women (67%), and their mean age was 92.3. The majority (80%) were widowed, 13% were married, and 7% were single. Mean hospitalization stay was 11.7 days. Ninety percent of patients lived at home before admission. Table 1 shows the main admission diagnoses. Mean BI previous to admission was 72; 26 patients (14%) maintained complete independence in ADLs (BI 100), and 93 patients (51%) had a BI superior to 79. The mean standard deviation CCS was 1.8 0.4. In-hospital mortality was 20%. In 83 patients, the scheduled follow-up was not possible 1 year after discharge; 52 had died, nine were lost to follow-up, and 21 had a hospital readmission. The mean BI of the remaining surviving 64 patients after 1 year of hospital admission was 67, significantly higher than their BI at discharge (52; P .001), although lower than before admission (81; P .001). The BI after 1 year was similar to that at 3-month follow-up (69; P .7). Seventy-nine percent of patients had similar BI at 3-month and 12-month follow-up. A decline in BI persisted in 64% of patients, and only 23 patients (36%) returned to their previous ability. Total mortality rate was 48%. Eleven percent of the patients could not return to their preadmission dwelling. These results, as supported by previous data from other studies about the oldest-old, indicate that the majority are women, usually widowed, and living at home. 8 A remarkably low prevalence of institutionalization (10%) previous to admission was found. Many nonagenarians are functionally independent despite their advanced age. 1 More than 50% of our patients had good functional status before admission. The functional decline after hospitalization has a multifactorial, interactive, cumulative etiology, 5 and often disability persists 12 months later. 9 The loss of functional capacity in our population after 1 year of hospital admission is important. The declines in functionality may be the cumulative result of the failure to recover and an additional functional losses. 3 Although the effect of a new hospitalization was excluded, only 36% of the patients maintained their previous BI 1 year later. In these patients, this functional decline showed a tendency to recover at 3month follow-up, but BI did not increase further in most of them during the period analyzed. Even though this decline in ADLs occurred, as previously reported, 2,10 most hospitalized nonagenarians returned to their previous living conditions after discharge. The high rate of mortality in this elderly population with a limiting heterogeneity of diagnosis may be due to high frailty of nonagenarians after any hospital admission. Acute care hospitals must adopt methods to implement approaches to prevent the persistent loss in ability to perform ADLs observed in hospitalized elderly. Alternative Table 1. Distribution of the Main Diagnoses at Admission of the 182 Nonagenarian Patients Included in the Study