Feature ArticleMeasurement of function in older adults transitioning from hospital to home: an integrative review
Introduction
Adults aged 65 and older are discharged from the hospital more often than any other age group, accounting for 40% of hospital discharges in the US in 2010 (‘National Hospital Discharge Survey,’ 2012). Hospitalizations are consequential for older adults, as about 50% will experience functional decline.1, 2, 3, 4 For the purpose of this review, functional decline refers to a decline in activities of daily living (ADLs) or instrumental activities of daily living (IADLs). In addition, up to 50% of older adults do not recover their pre-hospitalization functional status during their first 30–90 days back home.1, 3, 4, 5 Older adults experiencing functional decline after discharge to home are particularly vulnerable because they may have less physical support than those discharged to rehabilitation centers, assisted living, or long-term care. Additionally, transitional care models developed to support older adults transitioning from hospital to home have not included functional status as a primary study variable.6, 7, 8, 9 Therefore, the transition between hospital and home is a critical interval during which older adults experience high rates of functional decline.
To determine the effectiveness of interventions to prevent functional decline, researchers must have instruments that are reliable and valid for use with older adults.10 Reliability refers to repeatability or consistency of scores on an instrument.11 Validity indicates that a tool is measuring what it is intended to measure.11 Currently, there is considerable variability in how functional status is measured in older adults.12 The instruments most commonly used to measure ADLs or IADLs were developed several decades ago to assess function by direct observation of patient performance in those undergoing rehabilitation for musculoskeletal conditions.13, 14, 15 However, these instruments have subsequently been applied to many different groups of older adults (e.g., community-based, hospital-based, and across many diagnoses). Additionally, functional status instruments are commonly administered by self-report, rather than by observation of performance. Therefore, it is important to understand whether instruments used to measure functional status have had sufficient psychometric testing to validate their utility as self-report measures in various groups of older adults.
Given the high rates of functional decline among older adults transitioning from hospital to home, it is important to have instruments that are reliable and valid for measurements taken at once older adults return home, i.e., a community-dwelling population. Additionally, older adults transitioning from hospital to home are unique in that many remain in a stage of acute illness and are in a transitional phase. Hence, instruments must be able to track changes in function throughout that transitional phase, and evaluators should be able to compare repeated measures over various time points for interventions targeting this transition from hospital to home. Therefore, an instrument's test-retest reliability, i.e., consistency from one time to another, and sensitivity to change over time must be established to study such a population. Without proper testing of the instrument's validity, reliability, and sensitively to change, i.e. psychometric testing, it is unclear whether the instruments are consistently detecting actual changes in function.10 Thus, the purpose of this integrative review is to: (1) summarize the research uses and methods of administering functional status instruments, i.e., instruments measuring ADLs or IADLs, when investigating older adults transitioning from hospital to home, (2) examine the development and existing psychometric testing of the instruments, and (3) discuss gaps and implications for future research.
Section snippets
Search strategy
The authors conducted an integrative review from August 2016 through July 2017 in CINAHL, PUBMED, Cochrane Library, and Web of Science for peer-reviewed English original research studies that assessed functional status in older adults transitioning from hospital to home. The following search terms were used in combination to identify articles: (1) functional status OR functional decline OR activities of daily living OR functional loss OR functional recovery OR functional independence OR
Search results
Five hundred seventeen publications were identified by title through the database searches. Twenty-five additional publications were identified through bibliography review. Two hundred eight publications remained after duplicate records were removed. Each of the 208 publications was screened by abstract (by DL, LB, and BK) resulting in exclusion of 129 records not meeting inclusion criteria. The remaining 79 publications were reviewed in full for eligibility. Forty publications were determined
Discussion
This integrative review reveals that the instruments most commonly used to measure functional status, i.e., ADLs and IADLs, in older adults transitioning from hospital to home are not administered as originally designed. Each of the instruments, with the exception of the ADL Summary Scale, was developed for observation (of performance)-based assessments. However, the large majority of the studies measuring functional status as an outcome in older adults transitioning from hospital to home rely
Acknowledgements
The project described was supported by the Clinical and Translational Science Award (CTSA) program, through the NIH National Center for Advancing Translational Sciences (NCATS), grant UL1TR000427. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.”
References (80)
- et al.
Prevalence of functional disability in activities of daily living (ADL), instrumental activities of daily living (IADL) and associated factors, as predictors of morbidity and mortality
Arch Gerontol Geriatr
(2010) - et al.
Variability in measuring (instrumental) activities of daily living functioning and functional decline in hospitalized older medical patients: a systematic review
J Clin Epidemiol
(2011) - et al.
ROBIS: a new tool to assess risk of bias in systematic reviews was developed
J Clin Epidemiol
(2016) - et al.
The Barthel Index: comparing inter-rater reliability between Nurses and Doctors in an older adult rehabilitation unit
Appl Nurs Res
(2011) - et al.
Improving the sensitivity of the Barthel Index for stroke rehabilitation
J Clin Epidemiol
(1989) - et al.
Geriatric conditions in acutely hospitalized older patients: prevalence and one-year survival and functional decline
PLoS ONE
(2011) - et al.
Factors associated with functional decline of hospitalised older persons following discharge from an acute geriatric unit
Ann Acad Med Singapore
(2006) - et al.
Hospital-associated functional decline: the role of hospitalization processes beyond individual risk factors
J Am Geriatr Soc
(2015) - et al.
Trajectories and predictors of functional decline of hospitalised older patients
J Clin Nurs
(2013) - et al.
Low-cost transitional care with nurse managers making mostly phone contact with patients cut rehospitalization at a VA hospital
Health Aff
(2012)
Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial
JAMA
Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial
J Am Geriatr Soc
Comparison of evidence-based interventions on outcomes of hospitalized, cognitively impaired older adults
J Comp Eff Res
Instruments for the functional assessment of older patients
NEJM
Research methods knowledge base
Assessing older persons
Studies of illness in the aged. The index of adl: a standardized measure of biological and psychosocial function
JAMA
Functional evaluation: the barthel index
Md State Med J
Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement
Ann Intern Med
Multidisciplinary studies of illness in aged persons II: a new classification of functional status in activities of daily living
J Chronic Dis
Relationship between quality of care and functional decline in hospitalized vulnerable elders
Med Care
Urinary incontinence and indwelling urinary catheters in acutely admitted elderly patients: relationship with mortality, institutionalization, and functional decline
J Am Med Dir Assoc
Serum IL-6 and IGF-1 improve clinical prediction of functional decline after hospitalization in older patients
Aging Clin Exp Res
Health-related quality of life at admission is associated with postdischarge mortality, functional decline, and institutionalization in acutely hospitalized older medical patients
J Am Geriatr Soc
Clinical characteristics and outcomes of hospitalized older patients with distinct risk profiles for functional decline: a prospective cohort study
PLoS ONE
Prediction of functional decline in older hospitalized patients: a comparative multicenter study of three screening tools
Aging Clin Exp Res
The prediction of functional decline in older hospitalised patients
Age Ageing
Identification of older hospitalised patients at risk for functional decline, a study to compare the predictive values of three screening instruments
J Clin Nurs
Impact of hospital admission on functional and cognitive measures in older subjects
Eur Geriatr Med
Prognostic significance of the short physical performance battery in older patients discharged from acute care hospitals
Rejuvenation Res
Proton pump inhibitors and functional decline in older adults discharged from acute care hospitals
J Am Geriatr Soc
Relation between symptoms of depression and health status outcomes in acutely ill hospitalized older persons
Ann Intern Med
Reports of financial disability predict functional decline and death in older patients discharged from the hospital
J Gen Intern Med
Use of an ambulation assistive device predicts functional decline associated with hospitalization
J Gerontol A Biol Sci Med Sci
Depressive symptoms after hospitalization in older adults: function and mortality outcomes
J Am Geriatr Soc
Disparities between black and white patients in functional improvement after hospitalization for an acute illness
J Am Geriatr Soc
Cognitive screening predicts magnitude of functional recovery from admission to 3 months after discharge in hospitalized elders
J Gerontol A Biol Sci Med Sci
Recovery of activities of daily living in older adults after hospitalization for acute medical illness
J Am Geriatr Soc
Hospitalization-associated disability in adults admitted to a safety-net hospital
J Gen Intern Med
Improved functional ability and independence in activities of daily living for older adults at high risk of hospital readmission: a randomized controlled trial
J Eval Clin Pract
Cited by (19)
Validation of the ACS NSQIP surgical risk calculator in older patients with colorectal cancer undergoing elective surgery
2022, Journal of Geriatric OncologyCitation Excerpt :Incontinence has a high prevalence in the older population, and many older patients who experience incontinence are still able to take care of themselves. The modified Katz-1 is a validated tool [21–24] and had more agreement with the given definition of functional dependency of the ACS NSQIP calculator than the original Katz-ADL. When the Katz ADL was not scored and no deficits were registered in the medical record, functional status was entered in the calculator as ‘independent’.
Assessing the efficacy of Naoxintong capsules on wound healing in post-craniotomy patients: A clinical perspective
2024, International Wound JournalAssessment of Elbow Rehabilitation Using Single DOF Robotic Exoskeleton
2023, Moratuwa Engineering Research Conference, MERConKnow thyself: Executive functioning and sex predict self-appraisal of functional abilities in community-dwelling older adults
2023, Clinical Neuropsychologist