Elsevier

Geriatric Nursing

Volume 39, Issue 3, May–June 2018, Pages 336-343
Geriatric Nursing

Feature Article
Measurement of function in older adults transitioning from hospital to home: an integrative review

https://doi.org/10.1016/j.gerinurse.2017.11.003Get rights and content

Abstract

Older adults often experience decline in functional status during the transition from hospital to home. In order to determine the effectiveness of interventions to prevent functional decline, researchers must have instruments that are reliable and valid for use with older adults. The purpose of this integrative review is to: (1) summarize the research uses and methods of administering functional status instruments 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. The authors conducted an integrative review of forty research studies that assessed functional status in older adults transitioning from hospital to home. This review reveals important gaps in the functional status instruments' psychometric testing, including limited testing to support their validity and reliability when administered by self-report and limited evidence supporting their ability to detect change over time.

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.”

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