住院老年患者日常生活能力受损的相关因素分析

目的分析住院老年患者日常生活能力(ADL)受损相关因素,为老年人群提供合理的医疗照护服务。方法对2016年10月至2017年3月宜宾市第二人民医院老年医学科住院期间的100例老年患者进行老年综合评估,分析ADL受损与慢性疾病、居家照护、老年综合评估间的关系。应用SPSS 22.0软件进行统计学分析。根据数据类型,单因素相关分析连续变量采用Spearman相关分析,二分类变量采用χ2检验,多因素相关分析采用logistic回归法。结果纳入的100例老年患者中,ADL受损共37人,ADL(5.22±1.36)分。ADL受损单因素相关分析显示ADL与年龄、握力、微型营养评定法简版(MNA-SF)、简易精神状态量表(MMSE)、跌倒病史相关(P0.05),多因素相关分析显示ADL与年龄、居家陪护、握力、跌倒病史相关(P0.05);ADL受损程度与性别、MMSE独立相关(P0.05),与其他各组分不能明确有无相关关系。结论针对ADL受损的老人,可以通过锻炼握力、预防跌倒、加强营养、预防痴呆等预防功能状态的下降。     

Exercising body and mind: an integrated approach to functional independence in hospitalized older people

OBJECTIVES: To evaluate the effect of a structured, multi-component, early rehabilitation program on functional status, delirium, and discharge outcomes of older acute medical inpatients.
DESIGN: Prospective controlled trial with blinded outcome evaluation.
SETTING: Internal medicine service of a metropolitan tertiary teaching hospital in Brisbane, Australia.
PARTICIPANTS: One hundred twenty-four consecutive inpatients aged 65 and older admitted from the emergency department to control or intervention medical ward. Exclusions included patients completely dependent before admission or admitted from a nursing home, patients too ill to participate or terminally ill, and patients with length of stay less than 72 hours.
INTERVENTION: Early physiotherapy review with provision of an individualized graduated exercise program and activity diary, progressive encouragement of functional independence by nursing staff and other members of the multidisciplinary team, and cognitive stimulation sessions.
MEASUREMENTS: Modified Barthel Index (MBI) at admission and discharge, timed up-and-go at admission and discharge, incidence of delirium and falls, measured activity, length of hospital stay, discharge destination, 30-day readmission rate.
RESULTS: Intervention and control participants were well matched in terms of age, sex, diagnosis, and functional status. The intervention group had greater improvement in functional status than the control group, with a median MBI improvement of 8.5 versus 3.5 points ( P =.03). In the intervention group, there was a reduction in delirium (19.4% vs 35.5%, P =.04) and a trend to reduced falls (4.8% vs 11.3%, P =.19). Length of stay, timed up-and-go, discharge destination, and readmissions did not differ between the groups.
CONCLUSION: This intervention was effective in improving function in a vulnerable patient group.     

Predictors of recovery in activities of daily living among disabled older persons living in the community

Objective  To identify the factors that predict recovery in activities of daily living (ADLs) among disabled older persons living in the community. Design  Prospective cohort study with 2-year follow-up. Setting  General community. Participants  213 men and women 72 years or older, who reported dependence in one or more ADLs. Measurements and Main Results  All participants underwent a comprehensive home assessment and were followed for recovery of ADL function, defined as requiring no personal assistance in any of the ADLs within 2 years. Fifty-nine participants (28%) recovered independent ADL function. Compared with those older than 85 years, participants aged 85 years or younger were more than 8 times as likely to recover their ADL function (relative risk [RR] 8.4; 95% confidence interval [CI] 2.7. 26). Several factors besides age were associated with ADL recovery in bivariate analysis, including disability in only one ADL, self-efficacy score greater than 75, Folstein Mini-Mental State Examination (MMSE) score of 28 or better, high mobility, score in the best third of timed physical performance, fewer than five medications, and good nutritional status. In multivariable analysis, four factors were independently associated with ADL recovery—age 85 years or younger (adjusted RR 4.1; 95% CI 1.3, 13), MMSE score of 28 or better (RR 1.7; 95% CI 1.2, 2.3), high mobility (RR 1.7; 95% CI 1.0, 2.9), and good nutritional status (RR 1.6; 95% CI 1.0, 2.5). Conclusions  Once disabled, few persons older than 85 years recover independent ADL function. Intact cognitive function, high mobility, and good nutritional status each improve the likelihood of ADL recovery and may serve as markers of resilliency in this population. Presented at the annual meeting of the American Geriatric Society, Chicago, Ill., May 4, 1996. Funded in part by the Claude D. Pepper Older Americans Independence Center (P60-AG10469) and by grant R01-AG07449 from the National Institute on Aging, Bethesda, Md., and was conducted while Dr. Gill was a Pfizer/AGS Postdoctoral Fellow. Dr. Gill is currently supported as a Robert Wood Johnson Foundation Generalist Physician Faculty Scholar and as a Paul Beeson Physician Faculty Scholar in Aging Research. Dr. Robison was supported by a Research Training Award in the Epidemiology of Aging from the National Institute on Aging (5T32-AG00153).     

A clinical index to stratify hospitalized older adults according to risk for new-onset disability

BACKGROUND: Many older adults who are independent prior to hospitalization develop a new disability by hospital discharge. Early risk stratification for new‐onset disability may improve care. Thus, this study's objective was to develop and validate a clinical index to determine, at admission, risk for new‐onset disability among older, hospitalized adults at discharge. DESIGN: Data analyses derived from two prospective studies. SETTING: Two teaching hospitals in Ohio. PARTICIPANTS: Eight hundred eighty‐five patients aged 70 years and older were discharged from a general medical service at a tertiary care hospital (mean age 78, 59% female) and 753 patients discharged from a separate community teaching hospital (mean age 79, 63% female). All participants reported being independent in five activities of daily living (ADLs: bathing, dressing, transferring, toileting, and eating) 2 weeks before admission. MEASUREMENTS: New‐onset disability, defined as a new need for personal assistance in one or more ADLs at discharge in participants who were independent 2 weeks before hospital admission. RESULTS: Seven independent risk factors known on admission were identified and weighted using logistic regression: age (80–89, 1 point; ≥90, 2 points); dependence in three or more instrumental ADLs at baseline (2 points); impaired mobility at baseline (unable to run, 1 point; unable to climb stairs, 2 points); dependence in ADLs at admission (2–3 ADLs, 1 point; 4–5 ADLs, 3 points); acute stroke or metastatic cancer (2 points); severe cognitive impairment (1 point); and albumin less than 3.0 g/dL (2 points). New‐onset disability occurred in 6%, 13%, 18%, 34%, 35%, 45%, 50%, and 87% of participants with 0, 1, 2, 3, 4, 5, 6, and 7 or more points, respectively, in the derivation cohort (area under the receiver operating characteristic curve (AUC)=0.784), and in 8%, 10%, 27%, 38%, 44%, 45%, 58%, and 83%, respectively, in the validation cohort (AUC=0.784). The risk score also predicted (P<.001) disability severity, nursing home placement, and long‐term survival. CONCLUSION: This clinical index determines risk for new‐onset disability in hospitalized older adults and may inform clinical care.     

The activities of daily vision scale: a useful tool to assess fall risk in older adults with vision impairment

OBJECTIVE: To evaluate the validity of the Activities of Daily Vision Scale (ADVS) as a tool to assess fall risk in older adults with vision impairment. DESIGN: Cross-sectional assessments of visual function and retrospective collection of fall data. SETTING: The outpatient medical clinics of an academic tertiary care community hospital. PARTICIPANTS: Randomly selected sample (n = 143) of older (> or = 65 years) patients seen at the outpatient medical clinics at Nassau County Medical Center in Long Island, New York. These patients had one or more of five ocular conditions: refractive errors (n = 90), cataracts (n = 77), glaucoma (n = 29), diabetic retinopathy (n = 19), and/or macular degeneration (n = 6). MEASUREMENTS: Visual function, assessed using the ADVS, demonstrated scores ranging from 0 (marked visual disability) to 100 (no visual difficulty). Fall history and the presence of eye disease were based on the self-recall of patients. Fall history was assessed retrospectively over a 1-year period from the time of the interview. RESULTS: Thirteen percent of the subjects reported having one or more falls during the 1-year period before the time of the interview. These subjects scored significantly lower on the ADVS compared with the scores of the group that did not report falls (74 +/- 22 vs 85 +/- 14, P < .01). Using a cutoff score of 90 points (10% loss of visual function on the ADVS), the ADVS had a 67% sensitivity in identifying those patients who had falls. Among the patients with glaucoma and those with diabetic retinopathy, the ADVS had a 100% sensitivity in identifying those patients who reported a history of falls. In patients with cataracts and refractive errors, the ADVS had a sensitivity of 82% and 64%, respectively, in identifying patients with a history of falls. The number of falls reported by the subjects showed no relationship with the ADVS scores. CONCLUSION: The results from this study suggest that the ADVS may prove to be a useful tool to assess fall risk in older adults with vision impairment, especially in those persons with glaucoma, diabetic retinopathy, and/or cataracts.     

Effects of provider practice on functional independence in older adults

OBJECTIVES: To examine provider determinants of new-onset disability in basic activities of daily living (ADLs) in community-dwelling elderly. DESIGN: Observational study. SETTING: King County, Washington. PARTICIPANTS: A random sample of 800 health maintenance organization (HMO) enrollees aged 65 and older participating in a prospective longitudinal cohort study of dementia and normal aging and their 56 primary care providers formed the study population. MEASUREMENTS: Incident ADL disability, defined as any new onset of difficulty performing any of the basic ADLs at follow-up assessments, was examined in relation to provider characteristics and practice style using logistic regression and adjusting for case-mix, patient and provider factors associated with ADL disability, and clustering by provider. RESULTS: Neither provider experience taking care of large numbers of elderly patients nor having a certificate of added qualifications in geriatrics was associated with patient ADL disability at 2 or 4 years of follow-up (adjusted odds ratio (AOR) for experience=1.29, 95% confidence interval (CI)=0.81-2.05; AOR for added qualifications=0.72, 95% CI=0.38-1.39; results at 4 years analogous). A practice style embodying traditional geriatric principles of care was not associated with a reduced likelihood of ADL disability over 4 years of follow-up (AOR for prescribing no high-risk medications=0.56, 95% CI=0.16-1.94; AOR for managing geriatric syndromes=0.94, 95% CI=0.40-2.19; AOR for a team care approach=1.35, 95% CI=0.66-2.75). CONCLUSION: Taking care of a large number of elderly patients, obtaining a certificate of added qualifications in geriatrics, and practicing with a traditional geriatric orientation do not appear to influence the development of ADL disability in elder, community dwelling HMO enrollees.     

Problems of older adults living alone after hospitalization

OBJECTIVE: To describe functional deficits among older adults living alone and receiving home nursing following medical hospitalization, and the association of living alone with lack of functional improvement and nursing home utilization 1 month after hospitalization. DESIGN: Secondary analysis of a prospective cohort study. PARTICIPANTS: Consecutive sample of patients age 65 and over receiving home nursing following medical hospitalization. Patients were excluded for new diagnosis of myocardial infarction or stroke in the previous 2 months, diagnosis of dementia if living alone, or nonambulatory status. Of 613 patients invited to participate, 312 agreed. MEASUREMENTS: One week after hospitalization, patients were assessed in the home for demographic information, medications, cognition, and self-report of prehospital and current mobility and function in activities of daily living (ADLs) and independent activities of daily living (IADLs). One month later, patients were asked about current function and nursing home utilization. The outcomes were lack of improvement in ADL function and nursing home utilization 1 month after hospitalization. RESULTS: One hundred forty-one (45%) patients lived alone. After hospital discharge, 40% of those living alone and 62% of those living with others had at least 1 ADL dependency (P=.0001). Patients who were ADL-dependent and lived alone were 3.3 (95% confidence interval [95% CI], 1.4 to 7.6) times less likely to improve in ADLs and 3.5 (95% CI, 1.0 to 11.9) times more likely to be admitted to a nursing home in the month after hospitalization. CONCLUSION: Patients who live alone and receive home nursing after hospitalization are less likely to improve in function and more likely to be admitted to a nursing home, compared with those who live with others. More intensive resources may be required to continue community living and maximize independence. This work was supported by grants from the American Physical Therapy Foundation, the Dean Foundation, and the University of Wisconsin Medical School and Graduate School. Dr. Mahoney was the recipient of a Clinical Investigator Award from the NIA (K08AG00623).     

Research: Influence of different health‐care systems on health of older adults: A comparison of Hong Kong,Beijing urban and rural cohorts aged 70 years and older

Objective: To explore the hypothesis that better health status of elderly populations is primarily determined by the provision of freely accessible health service at low or no cost to the user and a social welfare system. Method: Information was collected by questionnaire from surveys of three cohorts of elderly (70 years and older) Chinese. Data from two health‐care systems were compared: the low‐cost or free government‐subsidised system in Hong Kong, and the market‐orientated user‐pays system in urban (Beijing), and rural China. Results: The Beijing rural cohort had the best health profile, whereas the Hong Kong cohort had the worst, despite the better lifestyle practices in the Hong Kong and Beijing urban cohorts compared with the Beijing rural cohort, and higher socioeconomic status in the Beijing urban and Hong Kong cohorts. However, the Beijing rural cohort had the highest prevalence of functional limitations. Conclusion: While health‐care systems may affect life expectancy at birth, psychosocial, lifestyle and socioeconomic factors influence subsequent health status of elderly people in a complex manner.