Hospitalization Preditcts Functional Decline in Nursing Home Patients

Abstract

Objectives: According to CMS data, a higher percentage of nursing home (NH) patients in Hawaii demonstrated functional decline than the national average. We examined the effects of hospitalization on functional and cognitive decline in elderly NH patients.

Design: Longitudinal observational study.

Setting: A 170-bed hospital-affiliated NH in Honolulu, Hawaii.

Participants: All patients admitted to the study NH between January 2003 and December 2006 (n=238) and followed from admission until discharge or death through 6/30/2011, using Minimum Data Set (MDS) assessments, NH and hospital medical records. We excluded patients with total Activities of Daily Living (ADL) dependence or severe cognitive impairment (Cognitive Performance Scale CPS=6) at baseline.

Measurements: Our primary outcome was change in function, measured by the MDS-ADL scale (range 1-28, higher=more disability) from admission and quarterly assessments. Our secondary outcome was change in cognition, measured with the MDS-CPS (range 0-6, higher=more cognitive impairment). For all patients, functional and cognitive decline over time was analyzed using multivariable linear regression analyses. Subgroup analysis examined those with at least one hospitalization and MDS data before and after hospitalization for within-person pre/post-hospitalization changes in ADL and CPS scores without covariate adjustment.

Results: After exclusions, our analytic sample included 147 patients. Mean age was 82.9 years, 36.1% were male and 91.5% were Asian. Mean baseline ADL score was 18.2 (SD 5.4) and mean baseline CPS score was 2.9 (SD 1.4). Mean follow-up time was 1.5 years (SD 1.2). Linear regression adjusting for Charlson Comorbidity Index showed increased ADL disability (2.9 points, 95%CI(2.13, 3.78), p<0.001) after hospitalization, with slight decreased disability by the 2nd MDS after NH readmission (-2.01, 95%CI(-1.35, -2.67), p<0.001). CPS score worsened by 0.47 (95%CI(0.28, 0.65), p<0.001). On within-person comparisons, ADL disability increased by 4.5 points (95%CI(4.3,5.8), p<0.001) after hospitalization, with slight decreased disability by the 2nd MDS assessment after NH readmission (-1.6, 95%CI(-3.2,-0.1), p=0.04). CPS score worsened by 0.7 points (95%CI(0.4,1.1), p<0.0001).

Conclusion: Hospitalization was significantly associated with increased functional decline among elderly NH patients, with slight improvement after readmission to the NH. Treatment of acute illness in the NH should be included as an option during goals of care discussions.