The effect on physical performance of a functional assessment and immediate rehabilitation of acutely admitted elderly patients with reduced functional performance: the design of a randomised clinical trial

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Abstract

Introduction

Illness and hospitalisation, even of short duration, pose separate risks for permanently reduced functional performance in elderly medical patients. Functional assessment in the acute pathway will ensure early detection of declining performance and form the basis for mobilisation during hospitalisation and subsequent rehabilitation. For optimal results rehabilitation should begin immediately after discharge.The aim of this study is to investigate the effect of a systematic functional assessment in the emergency department (ED) of elderly medical patients with reduced functional performance when combined with immediate postdischarge rehabilitation.

Method and analysis

The study is a two-way factorial randomised clinical trial. Participants will be recruited among patients admitted to the ED who are above 65 years of age with reduced functional performance. Patients will be randomly assigned to one of four groups: (1) functional assessment and immediate rehabilitation; (2) functional assessment and rehabilitation as usual; (3) assessment as usual and immediate rehabilitation; (4) assessment and rehabilitation as usual.

Primary outcome

30 s chair-stand test administered at admission and 3 weeks after discharge.

Ethics and dissemination

The study has been approved by the Regional Scientific Ethical Committees of Southern Denmark in February 2014. The study findings will be published in peer-reviewed journals and presented at national and international conferences.

Trial registration number:

ClinicalTrials.gov Identifier: NCT02062541.

Related collections

Most cited references 18

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Change in disability after hospitalization or restricted activity in older persons.

Thomas Gill, Heather Allore, Evelyne A Gahbauer … (2010)

Disability among older persons is a complex and highly dynamic process, with high rates of recovery and frequent transitions between states of disability. The role of intervening illnesses and injuries (ie, events) on these transitions is uncertain. To evaluate the relationship between intervening events and transitions among states of no disability, mild disability, severe disability, and death and to determine the association of physical frailty with these transitions. Prospective cohort study conducted in greater New Haven, Connecticut, from March 1998 to December 2008 of 754 community-living persons aged 70 years or older who were nondisabled at baseline in 4 essential activities of daily living: bathing, dressing, walking, and transferring. Telephone interviews were completed monthly for more than 10 years to assess disability and ascertain exposure to intervening events, which included illnesses and injuries leading to either hospitalization or restricted activity. Physical frailty (defined as gait speed >10 seconds on the rapid gait test) was assessed every 18 months through 108 months. Transitions between no disability, mild disability, and severe disability and 3 transitions from each of these states to death, evaluated each month. Hospitalization was strongly associated with 8 of the 9 possible transitions, with increased multivariable hazard ratios (HRs) as high as 168 (95% confidence interval [CI], 118-239) for the transition from no disability to severe disability and decreased HRs as low as 0.41 (95% CI, 0.30-0.54) for the transition from mild disability to no disability. Restricted activity also increased the likelihood of transitioning from no disability to both mild and severe disability (HR, 2.59; 95% CI, 2.23-3.02; and HR, 8.03; 95% CI, 5.28-12.21), respectively, and from mild disability to severe disability (HR, 1.45; 95% CI, 1.14-1.84), but was not associated with recovery from mild or severe disability. For all 9 transitions, the presence of physical frailty accentuated the associations of the intervening events. For example, the absolute risk of transitioning from no disability to mild disability within 1 month after hospitalization for frail individuals was 34.9% (95% CI, 34.5%-35.3%) vs 4.9% (95% CI, 4.7%-5.1%) for nonfrail individuals. Among the possible reasons for hospitalization, fall-related injury conferred the highest likelihood of developing new or worsening disability. Among older persons, particularly those who were physically frail, intervening illnesses and injuries greatly increased the likelihood of developing new or worsening disability. Only the most potent events, ie, those leading to hospitalization, reduced the likelihood of recovery from disability.

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Hospitalization, restricted activity, and the development of disability among older persons.

T Holford, Ryan Gill, Zhenchao Guo … (2004)

Preventing the development of disability in activities of daily living is an important goal in older adults, yet relatively little is known about the disabling process. To evaluate the relationship between 2 types of intervening events (hospitalization and restricted activity) and the development of disability and to determine whether this relationship is modified by the presence of physical frailty. Prospective cohort study, conducted in the general community in greater New Haven, Conn, from March 1998 to March 2003, of 754 persons aged 70 years or older, who were not disabled (ie, required no personal assistance) in 4 essential activities of daily living: bathing, dressing, walking inside the house, and transferring from a chair. Participants were categorized into 2 groups according to the presence of physical frailty (defined on the basis of slow gait speed) and were followed up with monthly telephone interviews for up to 5 years to ascertain exposure to intervening events and determine the occurrence of disability. Disability, defined as the need for personal assistance in bathing, dressing, walking inside the house, or transferring from a chair. During the 5-year follow-up period, disability developed among 417 (55.3%) participants, 372 (49.3%) were hospitalized and 600 (79.6%) had at least 1 episode of restricted activity. The multivariable hazard ratios for the development of disability were 61.8 (95% confidence interval [CI], 49.0-78.0) within a month of hospitalization and 5.54 (95% CI, 4.27-7.19) within a month of restricted activity. Strong associations were observed for participants who were physically frail and those who were not physically frail. Hospital admissions for falls were most likely to lead to disability. Intervening events occurring more than a month prior to disability onset were not associated with the development of disability. The population-attributable fractions associated with new exposure to hospitalization and restricted activity, respectively, were 0.48 and 0.19; 0.40 and 0.20, respectively, for frail participants and 0.61 and 0.16, respectively, for nonfrail participants. Illnesses and injuries leading to either hospitalization or restricted activity represent important sources of disability for older persons living in the community, regardless of the presence of physical frailty. These intervening events may be suitable targets for the prevention of disability.

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Reliability of the Barthel Index when used with older people.

Douglas Young, Gudrun Seebass, Aruna T Bansal … (2005)

the Barthel Index (BI) has been recommended for the functional assessment of older people but the reliability of the measure for this patient group is uncertain. To investigate this issue we undertook a systematic review to identify relevant studies from which an overview is presented. studies investigating the reliability of the BI were obtained by searching Medline, Cinahl and Embase to January 2003. Screening for potentially relevant papers and data extraction of the studies meeting the inclusion criteria were carried out independently by two researchers. the scope of the 12 studies identified included all the common clinical settings relevant to older people. No study investigated test-retest reliability. Inter-rater reliability was reported as 'fair' to 'moderate' agreement for individual BI items, and a high percentage agreement for the total BI score. However, these findings were difficult to interpret as few studies reported the prevalence of the disability categories for the study populations. There may be considerable inter-observer disagreement (95% CI of +/-4 points). There was evidence that the BI might be less reliable in patients with cognitive impairment and when scores obtained by patient interview are compared with patient testing. The role of assessor training and/or guidelines on the reliability of the BI has not been investigated. although the BI is highly recommended, there remain important uncertainties concerning its reliability when used with older people. Further studies are justified to investigate this issue.

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Author and article information

Journal

Journal ID (nlm-ta): BMJ Open

Journal ID (iso-abbrev): BMJ Open

Journal ID (hwp): bmjopen

Journal ID (publisher-id): bmjopen

Title: BMJ Open

Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )

ISSN (Electronic): 2044-6055

Publication date Collection: 2014

Publication date (Electronic): 17 June 2014

Volume: 4

Issue: 6

Electronic Location Identifier: e005252

Affiliations

[1 ]Department of Physiotherapy, Kolding Hospital, a part of Hospital Lillebaelt , Kolding, Denmark

[2 ]Centre for Applied Health Services Research, Institute of Public Health, University of Southern Denmark , Odense, Denmark

[3 ]Department of Public Health, Aarhus University , Aarhus, Denmark

[4 ]MarselisborgCentret, Danish Rehabilitation Research Center , Aarhus, Denmark

[5 ]National Public Health and Quality Improvement, Central Denmark Region , Aarhus, Denmark

[6 ]Spine Centre of Southern Denmark, Middelfart Hospital, a part of Hospital Lillebaelt , Middelfart, Denmark

[7 ]Institute of Regional Health Research, University of Southern Denmark , Middelfart, Denmark

[8 ]Emergency Department, Aabenraa Hospital, Hospital of Southern Jutland , Aabenraa, Denmark

[9 ]Institute of Regional Health Research, University of Southern Denmark , Aabenraa, Denmark

Author notes

[Correspondence to ] Inge Hansen Bruun; Inge.Hansen.Bruun@ 123456rsyd.dk

Article

Publisher ID: bmjopen-2014-005252

DOI: 10.1136/bmjopen-2014-005252

PMC ID: 4067830

PubMed ID: 24939812

SO-VID: 1cec4509-639c-4466-97b5-a3c56c2720a3

License:

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

History

Date received : 13 March 2014

Date revision received : 29 May 2014

Date accepted : 30 May 2014

The effect on physical performance of a functional assessment and immediate rehabilitation of acutely admitted elderly patients with reduced functional performance: the design of a randomised clinical trial

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Abstract

Introduction

Method and analysis

Primary outcome

Ethics and dissemination

Trial registration number:

Related collections

Functional role of amyloid

Most cited references 18

Change in disability after hospitalization or restricted activity in older persons.

Hospitalization, restricted activity, and the development of disability among older persons.

Reliability of the Barthel Index when used with older people.

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