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Care of the Aging Patient: From Evidence to Action |

Hospitalization-Associated Disability:  “She Was Probably Able to Ambulate, but I’m Not Sure”

Kenneth E. Covinsky, MD, MPH; Edgar Pierluissi, MD; C. Bree Johnston, MD, MPH
JAMA. 2011;306(16):1782-1793. doi:10.1001/jama.2011.1556.
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In older patients, acute medical illness that requires hospitalization is a sentinel event that often precipitates disability. This results in the subsequent inability to live independently and complete basic activities of daily living (ADLs). This hospitalization-associated disability occurs in approximately one-third of patients older than 70 years of age and may be triggered even when the illness that necessitated the hospitalization is successfully treated. In this article, we describe risk factors and risk stratification tools that identify older adults at highest risk of hospitalization-associated disability. We describe hospital processes that may promote hospitalization-associated disability and models of care that have been developed to prevent it. Since recognition of functional status problems is an essential prerequisite to preventing and managing disability, we also describe a pragmatic approach toward functional status assessment in the hospital focused on evaluation of ADLs, mobility, and cognition. Based on studies of acute geriatric units, we describe interventions hospitals and clinicians can consider to prevent hospitalization-associated disability in patients. Finally, we describe approaches clinicians can implement to improve the quality of life of older adults who develop hospitalization-associated disability and that of their caregivers.

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Figure. Factors Contributing to the Development of Hospitalization-Associated Disability
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Hospitalization-associated disability refers to patients who have a new disability in activities of daily living (ADLs) at hospital discharge that they did not have before the onset of the acute illness. This disability leads to the loss of independent functioning. It comprises patients who develop new disability between the onset of the acute illness and hospitalization, as well as those who develop new disability during their hospitalization. The risks for disability due to an acute illness before hospitalization and failure to recover functioning during hospitalization, as well as onset of a new disability during hospitalization, stem from the interaction of baseline functional reserve (vulnerability and capacity to recover), the precipitating event of the acute illness resulting in hospitalization, hospital processes that might contribute to disability, and factors affecting care after hospitalization discharge. Processes common to the development of geriatric syndromes include the interaction of baseline vulnerability and capacity to recover, the severity of precipitating events (acute illness), and care processes (hospital factors) that may inhibit functional recovery and promote further functional decline. IADLs indicate instrumental activities of daily living.
aIndicates that a new disability can occur at various points in the timeline between acute illness onset and hospital discharge.

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