What is Functional Decline?
Functional decline is a new loss of independence in self-care capabilities and is typically associated with deterioration in mobility and in the performance of activities of daily living (ADLs) such as dressing, toileting, and bathing. When older adults are hospitalized, the medical illness causing hospitalization can cause a decline in functional status. Functional decline can also be caused by other factors related to hospitalization such as extended bed rest, reduced daily participation in ADLs, iatrogenic events, and inappropriate use of mobility-restricting devices such as indwelling catheters and intravenous lines.
Why is Functional Decline an Important Issue in Hospitals?
- Functional Decline is a common problem in older people admitted to hospital:
- 30-60% of older people experience functional decline when acutely hospitalized1,2,3,4,5
- One year after hospital discharge, less than 50% of older adults recover to their pre-illness level of functioning and rates of long-term care placement are high6,7
- Processes of hospitalization may lead to Functional Decline:
- It is estimated that up to 50% of older adults experience functional decline during hospitalization that is largely independent of their presenting medical illness4,8,9
- Many factors related to processes across the hospital organization can contribute to functional decline
Factors Related to Hospitalization that Contribute to Functional Decline10
PC PROCESS OF CARE-RELATED FACTORS
EB EMOTIONAL AND BEHAVIOURAL ENVIRONMENT FACTORS
Phys PHYSICAL ENVIRONMENT FACTORS
- Functional Decline is associated with negative outcomes:
- Functional Decline is often difficult to reverse, and may lead to long term loss of independence, social isolation, and reduced quality of life6,7
- Increased hospital length of stay and increased rate of long term care admission
- Functional Decline during hospitalization can be prevented with prompt intervention involving the inter-professional team and including early interaction with patients and family caregivers
- Positive outcomes of multi-component interventions studied in academic and community hospitals include improved performance of ADLs, improved patient and provider satisfaction, decreased length of stay, decreased rates of discharge to long-term care homes, and lower overall hospital costs14,15,16,18
What are the foreseeable outcomes when Functional Decline is appropriately addressed?
- For the patient
- Improved mobility and independence in ADLs14,15,16,18
- Improved self esteem related to greater independence – elderly patients often view their health in terms of their function rather than their disease status17
- Reduced complications during hospitalization
- Improved rate of return to pre-hospital living environment14,15,16,18
- For hospital staff
- Improved ability to detect and prevent functional decline
- Improved inter-professional collaboration
- Empowerment and improved satisfaction when caring for older adults
- For the healthcare system
- Decreased institutionalization14,15,16,18
- Decreased length of stay18 and ALC rates
- Decreased costs of health care16
- Improved patient and family satisfaction14,15
What can be done across the organization to address Functional Decline?
1 McVey LJ, PM Becker, CC Saltz, JR Feussner, and HJ Cohen (1989). Effect of a geriatric consultation team on functional status of elderly hospitalized patients: A randomized, controlled clinical trial. Annals of Internal Medicine 110: 79-84.
2 Sager MA, T Franke, SK Inouye, CS Landefeld, TM Morgan, MA Rudberg, H Sebens, and CH Winograd (1996). Functional outcomes of acute medical illness and hospitalization in older persons. Archives of Internal Medicine 156: 645-652.
3 Mahoney JE, MA Sager, and M Jalaluddin (1999). Use of an ambulation assistive device predicts functional decline associated with hospitalization. The Journal of Gerontology, Series A, Biological Sciences and Medical Sciences 54: M83-M88.
4 Covinsky KE, RM Palmer, RH Fortinsky, SR Counsell, AL Stewart, D Kresevic, CJ Burant, and CS Landefeld (2003). Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: increased vulnerability with age. Journal of the American Geriatrics Society 51(4): 451-458.
5 Gill TM, HG Allore, EA Gahbauer, and TE Murphy (2010). Change in disability after hospitalization or restricted activity in older persons. Journal of the American Medical Association 304(17): 1919-1928.
6 Boyd CM, CS Landefeld, SR Counsell, RM Palmer, RH Fortinsky, D Kresevic, C Burant, and KE 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.
7 Brown CJ, DL Roth, RM Allman, P Sawyer, CS Ritchie, and JM Roseman (2009). Trajectory of life-space mobility after hospitalization. Annals of Internal Medicine 150(6): 372-378.
8 Sager MA, T Franke, SK Inouye, CS Landefeld, TM Morgan, MA Rudberg, H Sebens, and CH Winograd (1996). Functional outcomes of acute medical illness and hospitalization in older persons. Archives of Internal Medicine 156(6): 645-652.
9 Gill TM, HG Allore, TR Holford, and Z Guo (2004). Hospitalization, restricted activity, and the development of disability among older persons. Journal of the American Medical Association 292(17): 2115-2124.
10 Covinsky KE, E Pierluissi, and CB Johnston (2011). Hospitalization-Associated Disability – “She Was Probably Able to Ambulate, but I’m Not Sure.” Journal of the American Medical Association 306(16): 1782-1793.
11 Markey DW, and RJ Brown (2002). An interdisciplinary approach to addressing patient activity and mobility in the medical-surgical patient. Journal of Nursing Care Quality 16(4): 1-12.
12 Corcoran PJ (1991). Use it or lose it – the hazards of bed rest and inactivity. Western Journal of Medicine 154: 536-538.
13 Gillis A, and B MacDonald (2005). Deconditioning in the Hospitalized Elderly. The Canadian Nurse 101(6): 16-20.
14 Landefeld CS, RM Palmer, DM Kresevic, RH Fortinsky, and J Kowal (1995). A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. New England Journal of Medicine 332(20): 1338-1344.
15 Counsell SR, CM Holder, LL Liebenauer, RM Palmer, RH Fortinsky, DM Kresevic, LM Quinn, KR Allen, KE Covinsky, and CS Landefeld (2000). Effects of a multicomponent intervention on functional outcomes and process of care in hospitalized older patients: a randomized controlled trail of Acute Care for Elders (ACE) in a community hospital. Journal of the American Geriatrics Society 48(12): 1572-1581.
16 de Morton N, JL Keating, and K Jeffs (2007). Exercise for acutely hospitalized older medical patients. Cochrane Database of Systematic Reviews, Issue 1. Art No: CD005955. DOI: 10.1002/14651858.CD005955.pub2.
17 Dopp CA, and DV Jeste (2006). Definitions and predictors of successful aging: A comprehensive review of larger quantitative studies. American Journal of Geriatric Psychiatry 14(1): 6–20.
18 Padula CA, C Hughes, and L Baumhover (2009). Impact of a Nurse-Driven Mobility Protocol on Functional Decline in Hospitalized Older Adults. Journal of Nursing Care Quality 24(4): 325-331.