Monday, December 29, 2008
These are my final posts for 2009, and likely the last posts for Pallimed as well for the year as we've all been enjoying a lighter holiday posting schedule. Happy 2009 to all, and may it be a better (more peaceful and prosperous) year than 2008! (I'm speaking nationally and internationally here - the blog prospered plenty in 2008 - thank you readers & Christian & Tom & AAHPM - and I'll be happy to simply match it in 09!)
On to the articles:
Journal of the American Geriatrics Society has a paper hinting at the prognostic significance of a functional decline associated with acute illness and hospitalization in older patients. The data come from a prospective study of ~2300 hospitalized (non-ICU) older patients (mean age ~80 years) at two hospitals in Ohio in which patients' abilities to perform activities of daily living (ADLs) independently were assessed at the time of hospital discharge as well as two weeks prior to hospitalization. Vital and functional status were assessed regularly up to a year after discharge, allowing the researchers to compare survival in patients who 'lost function' during an acute hospitalization with those who didn't.
Patients discharge with at least one new ADL disability were older and sicker: had longer hospital stays (8 vs 5 days), more likely to have pre-existing functional impairments at baseline or live in a nursing home, and more likely to have dementia and COPD than those discharged without new disabilities. Not surprisingly the '-ADL' group did much worse: had a ~40% 1 year mortality vs 18% for the stable ADL group. In addition, in looking at how patients do at 1, 3, 6, and 12 months post discharge what seems to happen is that about 1/3 of the -ADL group recovers to baseline in a month. This ~1/3 of patients who return to baseline remains relatively constant for the rest of the year (about 1/3 of the -ADL patient group were at their baseline status at 12 months): the remaining 2/3 either has died or has persistent disabilities at 12 month.
The researchers noted that not returning to baseline at 1 month was a bad prognostic indicator for the -ADL group and described the natural history of those patients: only 17% went on to recover baseline function by the end of the year, 44% had died, and 38% had persistent deficits. While most patients' courses seemed to be 'set' at one month there were certainly patients whose status/courses changed after a month as well: of those who recovered to baseline at the end of the year 38% achieved that after one month, 20% of patients who did recover by one month had died by 1 year, etc.
Nevertheless the general trends are what are important: loss of function is associated with poor one year survival (40% mortality is worse than the mortality for newly diagnosed metastatic breast cancer in an 80 year old), and the one-month recovery mark seems to have some predictive power as well.
The paper's discussion talks mostly about the need for aggressive rehabilitation in these patients, which one can't argue with, but also begs the question of what is causing what? Are the worse outcomes here due to 'inadequate treatment' (in which case patients would indeed benefit from more aggressive/long-lasting rehab) or is loss of function/failure to regain function within a month more of a marker of illness/frailty/something else underlying the poorer prognosis which won't necessarily improve with rehab?
Cynthia M. Boyd, C. Seth Landefeld, Steven R. Counsell, Robert M. Palmer, Richard H. Fortinsky, Denise Kresevic, Christopher Burant, Kenneth E. Covinsky (2008). Recovery of Activities of Daily Living in Older Adults After Hospitalization for Acute Medical Illness Journal of the American Geriatrics Society, 56 (12), 2171-2179 DOI: 10.1111/j.1532-5415.2008.02023.x