Reference
Christine Loyd, Alayne D. Markland, Yue Zhang, Mackenzie Fowler, Sara Harper, Nicole C. Wright, Christy S. Carter, Thomas W. Buford, Catherine H. Smith, Richard Kennedy, Cynthia J. Brown, Prevalence of Hospital-Associated Disability in Older Adults: A Meta-analysis, Journal of the American Medical Directors Association, Volume 21, Issue 4, 2020, Pages 455-461.e5, ISSN 1525-8610, https://doi.org/10.1016/j.jamda.2019.09.015.
At a glance
The observation that 30% of hospitalized older adults, regardless of the length of stay, experience autonomy loss makes hospitalization an important risk factor of disability among the elderly.
What is already known
Hospital-related disability (HAD), also known as loss of independence in activities of daily living (ADL) at hospital discharge compared to pre-admission baseline, is a serious threat to independence and quality of life in the elderly, thus posing a burden on the healthcare system.
Study purpose
The general objective of the systematic review and meta-analysis herein described was to determine the overall prevalence of hospitalization-related disability, in terms of decline in ADL, in the elderly.
Study design and methods
The study is a meta-analysis of randomized controlled trials (RCTs) published in English language from major international databases—e.g., PubMed, Embase, CINHAL, Scopus, ProQuest, NICHSR ONESearch and ClinicalTrials.gov—aimed to identify the changes in ADLs among people aged ≥ 65 years in acute care units or medical-surgical units.
Eligible RCTs, prospective cohort studies and quasi-experimental studies were considered. For quasi-experimental studies, only patients in control groups were considered. All studies measured functional independence at two or more study time points—e.g., before admission and discharge or during hospitalization. Studies that included rehabilitation facilities, such as hospital rehabilitation units or acute care for elders units (ACE), were excluded.
Main findings
The meta-analysis examined 15 studies conducted between 1983 and 2013, for a total of 7,375 participants. Eleven studies were conducted in the USA, two in Italy, one in France and one in Israel. Thirteen studies assessed hospitalized patients, while the remaining two involved patients living in the community.
Among the hospitals included in the study, the prevalence of disability ranged from 17% to 61%, with an average of 30% (CI 95%: 24%, 36%; P < 0.001). Importantly, this value did not change when two studies on patients from psychiatric, cardiology and neurology units were included in the analysis. Likewise, the prevalence remained unchanged when two studies on patients treated in community hospitals were added to the analysis.
New findings
This review is the first to investigate ADLs in the elderly in the context of acute care. Furthermore, given the many geographical regions considered, it has good generalizability. Overall, the findings of this review call for the implementation of new helthcare approaches to limit disability in hospitalized elderly. One such approach could be the Acute Care Elderly (ACE) model.
Limitations of the study
Many studies were excluded due to lack of standardization and insufficient information about the process of evaluating or measuring the outcomes of ADL decline. Many of the patients included did not present diagnoses that directly impacted disability, such as stroke or hip fracture. The included studies showed high heterogeneity due to methodology, clinical differences between populations and publication bias. The results obtained may not be applicable to non-hospital settings.
Areas for future work
The study highlights how hospitalization can cause disabilities in older adults. Further studies are clearly needed to define a standardized methodology with which to identify and characterize ADLs. This tool would then improve our ability to measure the effectiveness of hospital care.
