Trajectories of life-space mobility after hospitalization

Life-space mobility trajectory patterns and associated characteristics in older cancer survivors: a secondary data analysis

BACKGROUND

Life-space mobility (LSM) measures the size of the real-world geographic area an individual purposely transverses in their daily life. While older cancer survivors often have declines in LSM that negatively affects their quality of life, independence, and social engagement the factors that predispose to adverse outcomes are unknown. Understanding different patterns of LSM and its decline can help identify those needing support. The purpose of this study was to identify: (1) LSM trajectory patterns and (2) factors associated with those patterns in older cancer survivors.

METHODS

This paper reports a secondary data analysis of 153 participants with cancer ≥ 65 years from the University of Alabama Study of Aging. LSM was assessed using the UAB Life-Space Assessment-Composite score (LSA-C) at study entry and every 6 months for 96 months (LSA-C < 60 = restricted LSM). LSM trajectory patterns based on the LSA-C were determined using group-based trajectory analysis. A classification tree analysis revealed factors that predicted the trajectory patterns.

RESULTS

Participants (n = 153) were a mean age of 76.1 (SD 6.33), mostly male (58%), White (58%), married (55%) or widowed (37%), and had a diagnosis of prostate (37.3%), breast (20.3%), or colon (11.8%) cancer. Three LSM trajectory patterns were identified: (1) high start and stable (37.3%) with unrestricted LSM (LSA-C = 81.2) at study entry, which remained stable over time, (2) high start progressive decline (27.5%) with unrestricted LSM (LSA-C = 78.0) at study entry that progressively declined, and (3) low start progressive decline (35.3%) with restricted LSM level (LSA-C = 42.0) at study entry, which progressively declined. Each pattern was associated with a unique set of demographic and clinical characteristics. Baseline physical performance score was the most important predictor of the LSM trajectory patterns.

CONCLUSIONS

Three distinct LSM trajectory patterns, each with unique demographic and clinical characteristics, were identified. Because older cancer survivors have distinct LSM patterns, interventions should be tailored to address specific characteristics and clinical needs. LSM measurement can contribute to assessment of older adults generally and should become part of standard assessment in older cancer survivors.

Impact of Delayed Postoperative Rehabilitation on Patients with Valvular Heart Disease: A Retrospective Cohort Study

Objectives

Delayed initiation of postoperative rehabilitation may be detrimental for improving everyday activities in postoperative patients with valvular heart disease. Rehabilitation is essential for postoperative valvular heart disease; however, the effective starting time of rehabilitation is unknown. This study aimed to investigate whether a delay in postoperative rehabilitation affects outcomes in patients after waiting for surgery for valvular heart disease.

Methods

Data from the JMDC database were extracted for 4330 patients diagnosed with valvular heart disease and who underwent surgery within 5 days of admission. Patient characteristics were compared between the usual rehabilitation group (started rehabilitation within 2 days postoperatively) and the delayed rehabilitation group (started rehabilitation at 3-5 days postoperatively). The primary outcome was hospitalization-associated disability (HAD); that is, the proportion of patients who showed a decline in the Barthel Index during hospitalization. Barthel Index at discharge, pulmonary complications following hospitalization, and postoperative complications were the secondary outcomes. Outcomes were compared in the usual and delayed rehabilitation groups after propensity score matching.

Results

Of the 4330 patients, 3845 patients were assigned to the usual rehabilitation group, and 485 patients were assigned to the delayed rehabilitation group. After propensity score matching, statistical analysis was performed on the usual and delayed rehabilitation groups, which each contained 418 patients. The delayed rehabilitation group had significantly higher rates of HAD (10.5% vs 8.1%) and respiratory complications (14.8% vs 11.2%) than the usual rehabilitation group.

Conclusions

Delayed postoperative rehabilitation may be associated with poor prognosis in patients with valvular heart disease.

Life-Space Restriction Following Disruptive Life Events: Evidence From the COVID-19 Pandemic

OBJECTIVES

Restriction of life-space mobility is associated with adverse health outcomes including depression, morbidity, mortality, and poorer quality of life. In this study, we aimed to determine the impact of coronavirus disease 2019 (COVID-19) and associated employment loss on the life space of older adults in Singapore.

METHODS

An in-person survey was administered to a cohort of older Singaporeans above 50 years old (N = 1,118). Data collected included self-report measures of life space, sensory function, well-being, cognitive function, depression, frailty, and objective measures of muscle mass and body mass index. Tests of association and linear regression were performed to test the hypotheses while accounting for the effects of health and sociodemographic covariates.

RESULTS

The life space of older adults has significantly diminished after the pandemic. This loss remained significant despite controlling for covariates and was more pronounced among those who had lost employment during the pandemic. In addition, losing employment during the pandemic was associated with having smaller life spaces.

DISCUSSION

Life-space assessments are a potential important noninvasive marker for not only health and longevity but also the ability to sustain employment. Public health crises like the COVID-19 pandemic and employment loss negatively affect the life spaces of older adults. It is needful to emphasize the maintenance of life space when faced with disruptive life events and provide multidisciplinary collaborative solutions to restore the quality of life among vulnerable older adults.

Non-emergent Conditions of the Ankle, Hindfoot, and Midfoot in Elderly Patients Are as Mobility Limiting as Congestive Heart Failure

BACKGROUND

Mobility limitations are well linked to increased morbidity and mortality. Older patients with chronic pathologies of the foot and ankle can suffer from significant mobility limitations; however, the magnitude of limitation experienced by this cohort is not well characterized. Conversely, the effects of congestive heart failure (CHF) on patient mobility are routinely assessed via the New York Heart Association (NYHA) classification. New York Heart Association classification is determined by a patient's physical activity limitation and is strongly correlated to functional status. We hypothesized that non-emergent conditions of the foot and ankle would be as mobility limiting as CHF.

METHODS

Life-Space Mobility Assessments (LSAs) were prospectively collected from orthopaedic patients at their preoperative visits and from CHF patients at a cardiology clinic. Patients over the age of 50 years were included in this study. Congestive heart failure patients NYHA class II or greater were included. The non-emergent foot and ankle cohort included Achilles tendonitis, ankle joint cartilage defects, ankle arthritis, subtalar arthritis, and midfoot arthritis. Patient demographics and LSA scores were analyzed using Mann-Whitney U and chi-squared tests.

RESULTS

A total of 96 elderly, non-emergent foot and ankle operative patients and 45 CHF patients met inclusion criteria. All medical comorbidities, except smoking status, were significantly more prevalent in the CHF cohort. No statistical difference was observed between CHF and preoperative foot and ankle LSA scores (56.1 vs 62.4, P = .320). Life-Space Mobility Assessment scores in the foot and ankle cohort were significantly improved relative to CHF patients, at 6-month and 1-year postoperative visits (P = .028, P < .0001, respectively).

CONCLUSION

Non-emergent ankle, hindfoot, and midfoot pathology is associated with similar mobility limitation to that of NYHA class II and III CHF. Older patients undergoing elective foot and ankle procedures exceeded the mobility of CHF patients at 6 months post-operation, and the mobility gains persisted at 1-year post-operation.

LEVELS OF EVIDENCE

Level II: Prospective cohort study.

Life-Space Activities and Incident Dementia Among Older Adults: Insights From a Cohort Study

OBJECTIVES

This study examined the association between life-space activities and incident dementia among older adults.

STUDY DESIGN

A prospective study.

SETTING AND PARTICIPANTS

This study included 2740 older adults (mean age 74.4 years; SD ± 6.2 years; range 65-99 years; 58.8% women).

METHODS

Life-space activities were assessed using the Active Mobility Index (AMI). Incident dementia was determined using medical insurance data and long-term care insurance data (mean follow-up, 53.7 months).

RESULTS

During the follow-up period, 326 participants (11.9%) had incident dementia. Participants were classified into 3 groups based on AMI score tertiles: tertile 1, ≤52; tertile 2, 53-77; and tertile 3, ≥78. The Cox proportional hazards model was used to examine the association between AMI scores and incident dementia. Individuals with higher scores had lower hazard ratios (HRs) (tertile 1: reference; tertile 2: adjusted HR, 0.76, 95% CI, 0.59-0.97, P = .027; tertile 3: adjusted HR, 0.49, 95% CI, 0.36-0.68, P < .001; P for trend: <.001). Both the physical and social AMI sub-scores were associated with dementia (P for trend: <.001).

CONCLUSIONS AND IMPLICATIONS

Restricted life-space activity, as assessed using the AMI, was associated with the risk of dementia. In addition, both the physical and social sub-scores were associated with dementia.

Trajectories of Physical Resilience Among Older Veterans With Stage 4 CKD

RATIONALE & OBJECTIVE

Although functional impairment is common among older adults with chronic kidney disease (CKD), functional reserve before an acute health event and physical resilience after the event have not been characterized in this population. The purpose of this study was to identify distinct patterns of physical function before and after an acute health event among older veterans with stage 4 CKD.

STUDY DESIGN

Prospective cohort study.

SETTING & PARTICIPANTS

National sample of veterans≥70 years of age with an estimated glomerular filtration rate (eGFR) of<30mL/min/1.73m2 who had an acute care encounter (emergency department visit or hospitalization) during the follow-up period (n = 272).

PREDICTORS

Demographic characteristics, eGFR, basic and instrumental activities of daily living (ADL/IADL) difficulty, symptom burden, cognition, depressive symptoms, social support.

OUTCOME

Function measured using the life-space mobility assessment obtained by telephone survey before and after an acute care encounter.

ANALYTICAL APPROACH

General growth mixture models to identify classes of functional trajectories. Calculation of percentages for demographic characteristics and means for eGFR, ADL/IADL difficulty, symptom burden, cognition, depressive symptoms, and social support by trajectory class.

RESULTS

Four trajectory classes were identified and characterized by different levels of life-space mobility before (reserve) and change in life-space mobility after (resilience) an acute care encounter: (1) low reserve, low resilience (n=91), (2) high reserve, high resilience (n=23), (3) moderate reserve, moderate resilience (n=89), and (4) high reserve, low resilience (n=69). Mean levels of ADL/IADL difficulty, symptom burden, cognition, and depressive symptoms, but not demographic characteristics, eGFR, or social support, differed by trajectory class.

LIMITATIONS

Veteran cohort was primarily male.

CONCLUSIONS

Among older adults with stage 4 CKD, physical function trajectories before and after an acute health event vary. Integrating reserve and resilience into care for this population may be useful for anticipating changes in function and developing tailored treatment plans.

What mobility factors are critical to include in a comprehensive mobility discharge assessment framework for older adults transitioning from hospital-to-home in the community? An international e-Delphi study

PURPOSE

To prioritize and achieve consensus on mobility determinant factors [cognitive, financial, environmental, personal, physical, psychological, social] considered critical to include in the COmprehensive Mobility Discharge Assessment Framework (COMDAF) for older adults transitioning from hospital-to-home.

MATERIALS AND METHODS

We conducted a three-round modified e-Delphi process with 60 international experts (seven older adults, nine family caregivers, 24 clinicians, and 20 researchers) from nine countries with universal or near-universal health coverage. Expert members rated 91 factors identified from scoping reviews using a 9-point scale: not important (1-3), important (4-6), and critical (7-9).

RESULT

A total of 41 of 91 factors (45.1%) met the a-priori consensus criterion after three rounds: five cognitive, five environmental, two personal, 19 physical, six psychological, and six social factors. No financial factors reached a consensus. The older adult steering committee member recommended the addition of two environmental factors, resulting in 43 mobility factors included in the COMDAF.

CONCLUSIONS

We advanced a comprehensive mobility framework by developing, through consensus, 43 mobility factors to be assessed as part of a COMDAF. However, its use in hospital-to-home may not be feasible. Therefore, future research will determine the core mobility factors for COMDAF and which measurement instruments best measure these factors.

RELEVANCE

An interdisciplinary discharge rehabilitation team can utilize the COMDAF during hospital-to-home transition.Implications for rehabilitationMobility assessment following a hospital discharge is a complex process requiring an interdisciplinary discharge rehabilitation team.This study provided a comprehensive list of 91 factors across all seven mobility determinants (cognitive, environmental, financial, personal, physical, psychological, and social) for clinicians in other care settings to use as a starting point to determine which mobility factor should be assessed during older adults' hospital-to-home transition.This international e-Delphi study identified 43 factors within mobility determinants (cognitive, environmental, personal, physical, psychological, and social) to be included in a Comprehensive Mobility Discharge Assessment Framework to assess older adults' mobility during the hospital to home transition.Using these 43 factors, clinicians can identify which assessment tool is best suited to assess the factors while reflecting on the logistics and feasibility; this is the next phase of this project.

Changes in Life-Space Mobility With Loss of Relatives and Friends Among Older Adults: Results From the UAB Study of Aging

BACKGROUND AND OBJECTIVES

Increasing age brings a greater risk of death of friends and family (hereafter referred to as loss) potentially impacting individuals' life-space mobility (LSM) trajectory.

RESEARCH DESIGN AND METHODS

Using the UAB study of aging, we examined differences in LSM trajectories of 1,000 community-dwelling older Alabamians (65 + years) with and without loss over 8.5 years. We measured LSM using UAB's Life-Space Assessment (LSA), a validated instrument assessing movement through zones ranging from their bedroom to out of town. We assessed loss every 6 months using a standard bereavement questionnaire capturing spousal, other relative, or friend loss. We used piecewise linear mixed-effects models to compare LSA trajectories.

RESULTS

At baseline, those who later experienced loss, compared with those who did not were younger, more likely to be female, and overall in better health. Those without loss had a baseline mean LSA score of 49.5 and a decline of 0.08 points per year (p < .001). Those with loss had a baseline LSA score of 60 and declined by 1.0 point per year before loss (p < .001), accelerating to 1.8 points per year after loss (p < .001).

DISCUSSION AND IMPLICATIONS

Those with loss do not experience acute decline postloss but do have an acceleration of the preexisting decline. Although additional research may explain the impact of loss on LSM; this finding suggests that more interventions such as social, mental, or health care services, may be needed for those who experience loss. Specifically, bereaved individuals may benefit from it.

Spatial scale effects on associations between built environment and cognitive function: Multi-Ethnic Study of Atherosclerosis

Built environments have the potential to favorably support cognitive function. Despite growing work on this topic, most of the work has ignored variation in the spatial scale of the effect. The issue with spatial scale effects is that the size and shape of the areal unit within which built environment characteristics are measured naturally influence the built environment exposure metric and thus the estimated associations with health. We used spatial distributed lag modeling (DLM) to estimate how associations between built environment exposures (walkable destinations [WD], social destinations [SD]) and change in cognition varied across distance of these destinations from participants' residences. Cognition was assessed as maintained/improved processing speed (PS) and global cognition (GC). Person-level data from Exam 5 (2010-2012) and Exam 6 (2016-2018) of the Multi-Ethnic Study of Atherosclerosis was used (N = 1380, mean age 67). Built environment data were derived from the National Establishment Time Series. Higher availability of walkable and social destinations at closer distance from participants' residence was associated with maintained/improved PS. The adjusted associations between maintained/improved PS and destinations waned with increasing distance from the residence; associations were evident until approximately 1.9-km for WD and 1.5-km for SD. Associations were most apparent for participants living in areas with high population density. We found little evidence for associations between change in GC and built environment at any distance. These results highlight the importance of identifying appropriate spatial scale to understand the mechanisms for built environment-cognition associations.

Effects of a Rehabilitation-at-Home Program Compared to Post-acute Skilled Nursing Facility Care on Safety, Readmission, and Community Dwelling Status: A Matched Cohort Analysis

OBJECTIVES

To evaluate the effectiveness and safety of Rehabilitation-at-Home (RaH), which provides high-frequency, multidisciplinary post-acute rehabilitative services in patients' homes.

DESIGN

Comparative effectiveness analysis.

SETTING AND PARTICIPANTS

Medicare Fee-For-Service patients who received RaH in a Center for Medicare and Medicaid Innovation Center Demonstration during 2016-2017 (N=173) or who received Medicare Skilled Nursing Facility (SNF) care in 2016-2017 within the same geographic service area with similar inclusion and exclusion criteria (N=5535).

METHODS

We propensity-matched RaH participants to a cohort of SNF patients using clinical and demographic characteristics with exact match on surgical and non-surgical hospitalizations. Outcomes included hospitalization within 30 days of post-acute admission, death within 30 days of post-acute discharge, length of stay, falls, use of antipsychotic medication, and discharge to community.

RESULTS

The majority of RaH participants were older than or equal to 85 years (57.8%) and non-Hispanic white (72.2%) with mean hospital length of stay of 8.1 (SD 7.6) days. In propensity-matched analyses, 10.1% (95% CI: 0.5%, 19.8) and 4.2% (95% CI: 0.1%, 8.5%) fewer RaH participants experienced hospital readmission and death, respectively. RaH participants had, on average, 2.8 fewer days (95% CI 1.4, 4.3) of post-acute care; 11.4% (95% CI: 5.2%, 17.7%) fewer RaH participants experienced fall; and 25.8% (95% CI: 17.8%, 33.9%) more were discharged to the community. Use of antipsychotic medications was no different.

CONCLUSIONS AND IMPLICATIONS

RaH is a promising alternative to delivering SNF-level post-acute RaH. The program seems to be safe, readmissions are lower, and transition back to the community is improved.

Short-Term, Community-Based, Slow-Stream Rehabilitation Program for Older Adults Transitioning from Hospital to Home: A Mixed Methods Program Evaluation

Introduction

Shortened hospital stays have shifted the burden of care for older adults to community, informal (ie, family, caregiver) and formal post-acute care and services, highlighting the need for effective post-hospital stay services and programs. As there is a dearth of information related to community-based, slow-stream rehabilitation program models for older adults transitioning from hospital to home in the Canadian context, the paper describes a mixed methods evaluation of such a program.

Materials and Methods

A mixed methods program evaluation, with process- and outcome-related elements, included 1) review and analysis of program documents; 2) observations to examine fidelity. Observation data were coded and summarized using descriptive statistics. Coded information and data were compared to document review data; 3) quantitative assessment of pre-post changes in physical, social, and psychological outcome measure and instrument scores using descriptive statistics, paired t-tests and confidence intervals (p = 0.05); and 4) exploration of acceptability through interviews and focus groups with 41 of the older adult participants and 17 family caregivers. Thematic analysis was used to examine focus group and interview transcripts.

Results

Observational data indicated alignment with the program document information overall. Statistically and clinically significant positive trends in improvement for physical outcome measure scores were observed (6-minute Walk Test, Life Space Assessment, Short Physical Performance Battery, Rapid Assessment of Physical Activity). Participants and family caregivers identified several positives and benefits of the program, ie, improvement in physical, social and mental well-being, decreased caregiver burden; and areas for improvement ie, need for more information about the program prior to enrollment and individualization, several of which aligned with the observation and quantitative data.

Discussion/Conclusion

This mixed methods program evaluation provided a detailed description of a community-based, slow-stream rehabilitation program for older adults who are transitioning to home post-hospital stay and its participants. Evidence of program fidelity, acceptability, and positive trends in improvement in physical outcome measure scores were found. Information about program strengths and areas for improvement can be used by stakeholders to inform program refinement and enhancement.

Recent functional decline and outpatient follow-up after hospital discharge: a cohort study

BACKGROUND

Functional decline is common following acute hospitalization and is associated with hospital readmission, institutionalization, and mortality. People with functional decline may have difficulty accessing post-discharge medical care, even though early physician follow-up has the potential to prevent poor outcomes and is integral to high-quality transitional care. We sought to determine whether recent functional decline was associated with lower rates of post-discharge physician follow-up, and whether this association changed during the COVID-19 pandemic, given that both functional decline and COVID-19 may affect access to post-discharge care.

METHOD

We conducted a retrospective cohort study using health administrative data from Ontario, Canada. We included patients over 65 who were discharged from an acute care facility during March 1st, 2019 - January 31st, 2020 (pre-COVID-19 period), and March 1st, 2020 - January 31st, 2021 (COVID-19 period), and who were assessed for home care while in hospital. Patients with and without functional decline were compared. Our primary outcome was any physician follow-up visit within 7 days of discharge. We used propensity score weighting to compare outcomes between those with and without functional decline.

RESULTS

Our study included 21,771 (pre-COVID) and 17,248 (COVID) hospitalized patients, of whom 15,637 (71.8%) and 12,965 (75.2%) had recent functional decline. Pre-COVID, there was no difference in physician follow-up within 7 days of discharge (Functional decline 45.0% vs. No functional decline 44.0%; RR = 1.02, 95% CI 0.98-1.06). These results did not change in the COVID-19 period (Functional decline 51.1% vs. No functional decline 49.4%; RR = 1.03, 95% CI 0.99-1.08, Z-test for interaction p = 0.72). In the COVID-19 cohort, functional decline was associated with having a 7-day physician virtual visit (RR 1.15; 95% CI 1.08-1.24) and a 7-day physician home visit (RR 1.64; 95% CI 1.10-2.43).

CONCLUSIONS

Functional decline was not associated with reduced 7-day post-discharge physician follow-up in either the pre-COVID-19 or COVID-19 periods. In the COVID-19 period, functional decline was positively associated with 7-day virtual and home-visit follow-up.

A protocol for randomized controlled trial on multidisciplinary interventions for mobility limitation in the older adults (M-MobiLE)

BACKGROUND

Mobility limitation-the loss of exercise capacity or independent living ability-is a common geriatric syndrome in older adults. As a potentially reversible precursor to disability, mobility limitation is influenced by various factors. Moreover, its complex physiological mechanism hinders good therapeutic outcomes with a single-factor intervention. Most hospitals have not incorporated the diagnosis and evaluation of mobility limitation into medical routines nor developed a multidisciplinary team (MDT) treatment plan. We aim to conduct a clinical trial titled "A Multidisciplinary-team approach for management of Mobility Limitation in Elderly (M-MobiLE)" to explore the effect of the MDT decision-making intervention for mobility limitation.

METHODS

The M-MobiLE study will be a multicenter, randomized, and controlled trial. We will recruit a minimum of 66 older inpatients with mobility limitation from at least five hospitals. Older patients with mobility limitation admitted to the geriatrics department will be included. Short-Physical Performance Battery (SPPB), Activities of Daily Living (ADL), Function Impairment Screening Tool (FIST), Geriatric Depression Scale (GDS-15), Short Form - 12 (SF-12), Fried frailty phenotype, social frailty, Morse Fall Risk Scale, SARC-CalF, Mini-Mental State Examination (MMSE), Mini-Nutritional Assessment Short-Form (MNA-SF), and intrinsic capacity will be assessed. The intervention group will receive an exercise-centered individualized MDT treatment, including exercise, educational, nutritional, medical, and comorbidity interventions; the control group will receive standard medical treatment. The primary outcome is the change in the SPPB score, and the secondary outcomes include increased SF-12, ADL, FIST, MMSE, MNA-SF, and intrinsic capacity scores and decreased GDS-15 and SARC-CalF scores.

CONCLUSION

Our results will help develop a multidisciplinary decision-making clinical pathway for inpatients with mobility limitation, which can be used to identify patients with mobility limitation more effectively, improve mobility, and reduce the risk of falls, frailty, and death in older inpatients. The implementation of this MDT strategy may standardize the treatment of mobility limitation, reduce adverse prognosis, and improve quality of life.

TRIAL REGISTRATION

ChiCTR, ChiCTR2200056756, Registered 19 February 2022.

The importance of context-a qualitative study exploring healthcare practitioners' experiences of working with patients at home after a stroke

BACKGROUND

Stroke significantly impacts individuals, leading to the need for long-lasting rehabilitation and adaptation to environmental demands. Rehabilitation after stroke is increasingly performed in patients' homes, and it is argued that rehabilitation in this context is more person-centred and positively impacts client outcomes. However, the role of environmental factors in this process is largely unknown. The aim of this study was to explore how multidisciplinary healthcare practitioners working with rehabilitation in the home after stroke consider possibilities and challenges in the environment and how environmental factors are documented in patients' records.

METHODS

Eight multidisciplinary healthcare practitioners working with home-based rehabilitation after stroke participated in two semistructured focus group sessions. Thematic analysis was used to analyse the transcripts of recorded focus group discussions. Data were also collected from patient history records (N = 14) to identify interventions to increase patients' opportunities to participate in activities inside and outside the home. These records were analysed using life-space mobility as a conceptual framework.

RESULTS

The analysis generated four overarching themes concerning possibilities and challenges in the environment: (1) the image of rehabilitation conflicts with place, (2) the person in the home reveals individual needs and capabilities, (3) environmental characteristics influence the rehabilitation practice, and (4) the person is integrated within a social context. The patient record analysis showed that most patients were discharged from hospital to home within four days. Assessments at the hospital mainly focused on basic activities of daily living, such as the patient's self-care and walking ability. Also at home, the assessments and actions primarily focused on basic activities with little focus on participation in meaningful activities performed in different life situations outside the home.

CONCLUSIONS

Our research suggests that one way to improve practice is to include the environment in the rehabilitation and consider the person´s life space. Interventions should focus on supporting out-of-home mobility and activities as part of person-centred stroke rehabilitation. This must be supported by clear documentation in the patient records to strengthen clinical practice as well as the communication between stakeholders.

Republication of "Assessment of Recovery From Geriatric Ankle Fracture Using the Life Space Mobility Assessment (LSA): A Pilot Study"

Background

The Life Space Assessment (LSA) is a validated outcomes measure that aims to assess the level of mobility and physical functioning within one's own environment following a medical event. We sought to study the recovery of geriatric ankle fracture patients utilizing the LSA. We hypothesized that the LSA would provide improved assessment of these patients and help identify key differences in operative and nonoperatively treated patients.

Methods

Prospective observational study of geriatric patients age 65 years and older with an ankle fracture with 1-year follow-up. Operative versus nonoperative intervention was determined by the attending physician on a patient-specific basis. The LSA, Short Form-36 (SF-36), and visual analog pain scale (VAPS) were administered at predetermined intervals postinjury and scores were analyzed for significance.

Results

20 patients were enrolled in this study. 11 underwent surgery whereas 9 were treated nonoperatively. Regardless of treatment, the preinjury LSA score was 86.7. This significantly dropped to 20.6 at 6 weeks and recovered to 73.6 at 12 months. In the operative cohort, the LSA scores preinjury were 91.4 and improved to 87.6 after 1 year. The nonoperative group recorded 80.9 preinjury and only improved to 59.5 at 1 year (P = 0.007). There was no statistically significant difference when comparing the results of the SF-36 and VAPS to the LSA.

Conclusion

The LSA was effective in assessing recovery in geriatric ankle fracture patients. A severe deficit in mobility was seen for the first 6 months of recovery regardless of treatment. Operative patients ultimately returned to their baseline LSA at 1 year while nonoperative patients did not. Outcomes from the VAS and SF-36 mirrored the LSA but were not found to be statistically significant.

Level of Evidence

Level II.

Life-space mobility and post-hospitalization outcomes among older Mexican American Medicare beneficiaries

BACKGROUND

Older adults with limited mobility are at an increased risk of adverse health outcomes, an outcome inadequately investigated in older Mexican Americans. We explored whether pre-admission life-space mobility predicts post-hospitalization outcomes among hospitalized Mexican American Medicare beneficiaries.

METHODS

Life-space mobility, using the Life-Space Assessment (LSA), was analyzed using quartiles and 5-point intervals. Using the Hispanic Established Populations for the Epidemiologic Study of the Elderly (HEPESE) Waves 7 and 8 data linked to Medicare claims data, 426 older Mexican Americans with at least 2 months of Medicare coverage who were hospitalized within 2 years of completing the LSA were included. Logistic and Cox Proportional regression analyses estimated the association of pre-admission LSA with post-hospitalization outcomes.

RESULTS

Prior to hospitalization, 85.4% reported limited life-space mobility. Most patients (n = 322, 75.6%) were hospitalized for medical reasons. About 65% were discharged to the community. Pre-admission LSA scores were not associated with community discharge (Odds Ratio [OR] = 1.02, 0.95-1.10). Higher pre-admission LSA scores were associated with 30-day readmission (OR = 1.11, 1.01-1.22). Patients in the highest pre-admission LSA quartile (i.e., greatest life-space mobility) were less likely to die within 2 years after hospital discharge (OR = 0.61, 0.39-0.97) compared to those with lower pre-admission LSA scores.

CONCLUSIONS

Among older Mexican American Medicare beneficiaries, greater pre-admission LSA scores were associated with an increased risk of 30-day readmission and a decreased risk of mortality within 2 years following hospitalization. Future work should further investigate the relationship between LSA and post-hospitalization outcomes in a larger sample of Mexican American older adults.

Hospital-associated disability due to avoidable hospitalizations among older adults

BACKGROUND

Hospital-associated disability (HAD) is a common complication during the course of acute care hospitalizations in older adults. Many admissions are for ambulatory care sensitive conditions (ACSCs), considered potentially avoidable hospitalizations-conditions that might be treated in outpatient settings to prevent hospitalization and HAD. We compared the incidence of HAD between older adults hospitalized for ACSCs versus those hospitalized for other diagnoses.

METHODS

We conducted a retrospective cohort study in inpatient (non-ICU) medical and surgical units of a large southeastern regional academic medical center. Participants were 38,960 older adults ≥ 65 years of age admitted from January 1, 2015, to December 31, 2019. The primary outcome was HAD, defined as decline on the Katz Activities of Daily Living (ADL) scale from hospital admission to discharge. We used generalized linear mixed models to examine differences in HAD between hospitalizations with a primary diagnosis for an ACSC using standard definitions versus primary diagnosis for other conditions, adjusting for covariates and repeated observations for individuals with multiple hospitalizations.

RESULTS

We found that 10% of older adults were admitted for an ACSC, with rates of HAD in those admitted for ACSCs lower than those admitted for other conditions (16% vs. 20.7%, p < 0.001). Age, comorbidity, admission functional status, and admission cognitive impairment were significant predictors for development of HAD. ACSC admissions to medical and medical/surgical services had lower odds of HAD compared with admissions for other conditions, with no significant differences between ACSC and non-ACSC admissions to surgical services.

CONCLUSIONS

Rates of HAD among older adults hospitalized for ACSCs are substantial, though lower than rates of HAD with hospitalization for other conditions, reflecting that acute care hospitalization is not a benign event in this population. Treatment of ACSCs in the outpatient setting could be an important component of efforts to reduce HAD.

Life-Space Mobility and Objectively Measured Movement Behavior in Older Adults with Hypertension after Receiving COVID-19 Vaccination

This study examined the changes in life-space (LS) mobility and objectively measured movement behavior in older adults with hypertension after receiving the COVID-19 vaccine and their associations with housing type. A total of 32 participants were included in this exploratory longitudinal study with a 1-year follow-up. LS mobility and accelerometer-based physical activity (PA) and sedentary behavior (SB) were assessed before and ~2 months after receiving COVID-19 vaccination. Participants residing in apartment/row housing showed an increase in LS mobility composite score (β = 14, p < 0.05). In addition, they showed an increase in light PA on weekdays and the weekend (β = 3.5%; β = 6.5%; p < 0.05) and a decrease in SB on weekdays and the weekend (β = -3.7%; β = -6.6%; p < 0.05). Furthermore, changes in SB pattern were found (less time spent in bouts of ≥10 and 30 min, more breaks/day and breaks/hour). Significant associations were found between changes in LS mobility composite score and PA (positive association) and SB (negative association) in older adults residing in apartment/row housing (p < 0.05). Older adults with hypertension, particularly those who resided in houses with limited outdoor space (apartment/row housing), showed positive changes in LS mobility and objectively measured movement behavior in a period after receiving the COVID-19 vaccine and characterized by social distancing policies without mobility restrictions when compared with the period of social distancing policies with high mobility restrictions and without vaccine.

Association of dual sensory impairment with changes in life space: A longitudinal study with two-year follow-up

OBJECTIVES

Dual sensory impairment (DSI) of hearing and vision in older adults may limit lifestyle activities of daily living and contribute to a reduced life space. This study aimed to investigate how DSI is associated with specific lifestyle activities and predicts changes in mobility in life space.

STUDY DESIGN

Participants comprised 4214 older adults (52.3 % female, mean age 75.8 years) who met the study's inclusion criteria. The participants were divided into three groups according to the number of sensory impairments: (1) no sensory impairment (NSI), (2) single sensory impairment (SSI), and (3) DSI.

MAIN OUTCOME MEASURE

We investigated the association between DSI and specific lifestyle activities at baseline. The Active Mobility Index (AMI) was used to assess life-space. Two years later, the association between DSI and life-space mobility was verified using multinomial logistic regression analysis.

RESULTS

DSI was more likely to have limited people's instrumental activities of daily living and cognitive, social, and productive activities at baseline (P < 0.05). In the adjusted model with potential covariates, people with DSI had a lower life-space score at 2 years than people with NSI (odds ratio [OR] = 1.40, 95 % confidence interval [CI]: 1.01-1.95), but the difference was not significant for SSI (OR = 0.98, 95 % CI: 0.78-1.24).

CONCLUSIONS

This study suggested that DSI was a factor that limited various activities and narrowed the life-space mobility of older adults. Prevention of DSI may be important for community-dwelling older adults to maintain a more active lifestyle.

The effectiveness of rehabilitation interventions including outdoor mobility on older adults' physical activity, endurance, outdoor mobility and falls-related self-efficacy: systematic review and meta-analysis

Objective

To determine the effectiveness of community-based rehabilitation interventions which incorporate outdoor mobility on physical activity, endurance, outdoor mobility and falls-related self-efficacy in older adults.

Design

MEDLINE, Embase, CINAHL, PEDro and OpenGrey were searched systematically from inception to June 2021 for randomised controlled trials (RCTs) of community-based rehabilitation incorporating outdoor mobility on physical activity, endurance, outdoor mobility and/or falls-related self-efficacy in older adults. Duplicate screening, selection, extraction and appraisal were completed. Results were reported descriptively and with random-effects meta-analyses stratified by population (proactive [community-dwelling], reactive [illness/injury]).

Results

A total of 29 RCTs with 7,076 participants were identified (66% high bias for at least one domain). The outdoor mobility component was predominantly a walking programme with behaviour change. Rehabilitation for reactive populations increased physical activity (seven RCTs, 587 participants. Hedge’s g 1.32, 95% CI: 0.31, 2.32), endurance (four RCTs, 392 participants. Hedges g 0.24; 95% CI: 0.04, 0.44) and outdoor mobility (two RCTs with 663 participants. Go out as much as wanted, likelihood of a journey) at intervention end versus usual care. Where reported, effects were preserved at follow-up. One RCT indicated a benefit of rehabilitation for proactive populations on moderate-to-vigorous activity and outdoor mobility. No effect was noted for falls-related self-efficacy, or other outcomes following rehabilitation for proactive populations.

Conclusion

Reactive rehabilitation for older adults may include walking programmes with behaviour change techniques. Future research should address the potential benefit of a walking programme for proactive populations and address mobility-related anxiety as a barrier to outdoor mobility for both proactive and reactive populations.

Many Paths to Recovery: Comparing Basic Function and Participation in High-Functioning Older Adults After Acute Hospitalization

Function after acute hospitalization is mostly operationalized by Basic Activities of Daily Living (BADL), a limited concept that overshadows a wide range of instrumental, social, and recreational activities, otherwise referred to as participation. Participation is important for patients' health and quality of life after hospitalization. This study focuses on high-functioning older adults, examining functional recovery after hospitalization by comparing BADL assessment with assessment of participation at one and three months following discharge relative to pre-hospitalization. Quantitative data were collected from 72 participants divided into two age groups of hospitalized older adults (age 65-74, n = 38; age ≥75, n = 34), followed by home visits after 1 month and telephone interviews 3 months after discharge. Both groups experienced a significantly greater decline in participation, compared with BADL, which were mostly preserved. A comprehensive assessment of participation better captures functional changes in high-functioning older adults. Early identification of participation withdrawal is crucial for preventing disability.

A multifactorial interdisciplinary intervention to prevent functional and mobility decline for more participation in (pre-)frail community-dwelling older adults (PromeTheus): study protocol for a multicenter randomized controlled trial

BACKGROUND

Age-related decline in physical capacity can lead to frailty, associated with an increased vulnerability to adverse health outcomes and greater healthcare utilization. In an aging population, effective strategies to prevent physical decline and frailty, and preserve independence are needed. Prevention programs for vulnerable community-dwelling older adults are, however, often not yet established and implemented in routine practice. Research on the feasibility, implementation, and (cost-)effectiveness of multifactorial, interdisciplinary intervention programs that take advantage of available services of healthcare providers is also limited. The main aim of this study is to evaluate the effectiveness of such an intervention program (PromeTheus) to prevent functional and mobility decline for more participation in community-dwelling (pre-)frail older adults.

METHODS

The study is designed as a three-center, randomized controlled trial with a 12-month intervention period. Four hundred community-dwelling (pre-)frail (Clinical Frailty Scale score 4-6) older adults (≥70 years) will be randomized in a 1:1 ratio to the intervention group (IG) or the control group (CG). The IG will receive the PromeTheus program consisting of obligatory home-based physical exercises (Weight-bearing Exercise for Better Balance) accompanied by physiotherapists and facultative counseling services (person-environment-fit, coping with everyday life, nutrition, group-based activities) delivered via existing healthcare structures (e.g., social workers, nutritionists). The CG will receive usual care and a one-time counseling session on recommendations for physical activity and nutrition. Primary outcomes assessed at months 6 and 12 are the function component of the Late-Life Function and Disability Instrument and the University of Alabama at Birmingham Life-Space Assessment. Secondary outcomes are disability, physical capacity and activity, frailty, nutritional status, falls, fear of falling, health status, and psychosocial components. Process and economic evaluations are also conducted. Primary statistical analyses will be based on the intention-to-treat principle.

DISCUSSION

Compared to usual care, the PromeTheus program is expected to result in higher function and mobility, greater independence and lower need for care, and more participation. As the PromeTheus program draws on existing German healthcare structures, its large-scale translation and delivery will be feasible, if evidence of (cost-)effectiveness and successful implementation can be demonstrated.

TRIAL REGISTRATION

German Clinical Trials Register, . Registered on March 11, 2021.

Minority Women

Perceptions of illness, pain, and death are not static. They vary among populations according to their cultural and biological characteristics. Older black and Hispanic/Latinx women are unique in their approach to health care with respect to mentation, mobility, medication adherence, and what matters to them. It is the complexity of these components, which affect the ability of these women to age gracefully.

Associations Between Active Mobility Index and Disability

OBJECTIVES

To develop a questionnaire-based Active Mobility Index (AMI) to assess going-out behavior with physical and social activity among older adults, and to assess the criterion-related and predictive validity of the AMI.

DESIGN

Prospective cohort study.

SETTING AND PARTICIPANTS

General community setting. Participants comprised 4432 older adults [mean age: 75.9 ± 4.3 (70-96) years; 2100 men (47.4%)].

METHODS

AMI assessed life-space and activities in each life-space (distance from the respondent's home: <1 km, 1-10 km, or >10 km) according to physical or social activity during the past 1 month by noting frequency, purpose, type of transportation, interaction with others, and physical activity. Baseline characteristics and outcomes were compared by AMI score quartiles (highest: Q4). To examine the criterion-related validity of AMI, depressive symptoms, frailty, and cognitive function were assessed. During follow-up, incident disability was monitored by Long Term Care Insurance certification.

RESULTS

Lower scores (Q1-Q3 groups) were associated with more depressive symptoms, frailty, and cognitive impairment compared with the Q4 group (all P < .001). Multiple logistic regression analyses revealed significantly higher odds ratios in the Q1 group in all health adverse outcomes compared with the Q4 group [depressive symptoms, odds ratio (OR) 3.94, 95% confidence interval (CI) 2.95-5.28; frailty, OR 3.20, 95% CI 2.31-4.44; cognitive impairment, OR 1.28, 95% CI 1.04-1.57]. Cox proportional hazards modeling indicated that the Q1 group had a higher risk of incident disability compared with the group (hazard ratio 1.53, 95% CI 1.24-1.88).

CONCLUSIONS AND IMPLICATIONS

AMI to assess life-space with physical and social activity among older people was associated with depressive symptoms, frailty, and cognitive impairment. Lower AMI scores were associated with higher incident disability risk. Further studies are needed to elucidate whether AMI is causally associated with incident adverse health outcomes.

Life-space mobility and healthcare costs and utilization in older men

OBJECTIVES

To determine the association of life-space score with subsequent healthcare costs and utilization.

DESIGN

Prospective cohort study (Osteoporotic Fracture in Men [MrOS]).

SETTING

Six U.S. sites.

PARTICIPANTS

A total of 1555 community-dwelling men (mean age 79.3 years; 91.5% white, non-Hispanic) participating in the MrOS Year 7 (Y7) examination linked with their Medicare claims data.

MEASUREMENTS

Life-space during the past month was assessed as 0 (daily restriction to one's bedroom) to 120 (daily trips outside one's town without assistance) and categorized (0-40, 41-60, 61-80, 81-100, 101-120). Total annualized direct healthcare costs and utilization were ascertained during 36 months after the Y7 examination.

RESULTS

Mean total annualized costs (2020 U.S. dollars) steadily increased across category of life-space score, from $7954 (standard deviation [SD] 16,576) among men with life-space scores of 101-120 to $26,430 (SD 28,433) among men with life-space scores of 0-40 (p < 0.001). After adjustment for demographics, men with a life-space score of 0-40 versus men with a life-space score of 101-120 had greater mean total costs (cost ratio [CR] = 2.52; 95% confidence interval [CI] = 1.84-3.45) and greater risk of subsequent hospitalization (odds ratio [OR] 4.72, 95% CI 2.61-8.53) and skilled nursing facility (SNF) stay (OR 7.32, 95% CI 3.65-14.66). Life-space score was no longer significantly associated with total healthcare costs (CR for 0-40 vs 101-120 1.29; 95% CI 0.91-1.84) and hospitalization (OR 1.76, 95% CI 0.89-3.51) after simultaneous consideration of demographics, medical factors, self-reported health and function, and the frailty phenotype; the association of life-space with SNF stay remained significant (OR 2.86, 95% CI 1.26-6.49).

CONCLUSION

Our results highlight the importance of function and mobility in predicting future healthcare costs and suggest the simple and convenient life-space score may in part capture risks from major geriatric domains and improve identification of older, community-dwelling men likely to require costly care.

Geographical life-space and subjective wellbeing in later life

Geographical life-space is an important factor to consider when studying subjective wellbeing of older adults. The purpose of this article is twofold: to provide an in-depth understanding of 1) the geographical life-spaces in which the lives of older adults take place and 2) the relation between life-space and experienced levels of subjective wellbeing. Seventy-six older adults (aged 65 and older) participated in our qualitative study. We applied a qualitative research approach, through combining indepth-interviews with visual life-space diagrams. Our findings show that most older adults continue to experience a high level of subjective wellbeing, regardless of the extent of their life-space. We conclude that the possibility to fulfill one's needs, even in a restricted life-space, is more conducive to maintaining subjective wellbeing than the extent of life-space itself.

Impact of COVID-19 Pandemic on Life-Space Mobility of Older Adults Living in Brazil: REMOBILIZE Study

Background: The COVID-19 pandemic hit Brazil in a scenario of substantial socioeconomic and health inequalities. It is unknown the immediate impact of social restriction recommendations (i.e., lockdown, stay-at-home) on the life-space mobility of older people. Objective: To investigate the immediate impact of COVID-19 pandemic on life-space mobility of community-dwelling Brazilian older adults and examine the social determinants of health associated with change in life-space mobility. Design: Baseline data from a prospective cohort study (REMOBILIZE Study). Setting: Community. Subject: A convenience snowball sample of participants aged 60 and older (n = 1,482) living in 22 states in Brazil. Methods: We conducted an online and phone survey using an adapted version of the Life-Space Assessment (LSA). Linear regression models were used to investigate social determinants of health on the change in LSA score. Results: Regardless of their gender and social determinants of health, participants showed a significant reduction in life-space mobility since COVID-19 pandemic outbreak. Life-space mobility reduction was higher among black individuals, those living alone and aged between 70 and 79. Other variables associated with change in life-space mobility, to a lesser extent, were sex, education and income. Conclusion: Social restriction measures due to pandemic caused substantial reduction in older adults' life-space mobility in Brazil. Social inequalities strongly affected vulnerable groups. Concerted actions should be put in place to overcome the deterioration in life-pace mobility amongst these groups. Failure in minimizing health inequalities amplified by the pandemic may jeopardize the desired achievements of the Decade of Healthy Aging.

Longitudinal course of GDF15 levels before acute hospitalization and death in the general population

Growth differentiation 15 (GDF15) is a potential novel biomarker of biological aging. To separate the effects of chronological age and birth cohort from biological age, longitudinal studies investigating the associations of GDF15 levels with adverse health outcomes are needed. We investigated changes in GDF15 levels over 10 years in an age-stratified sample of the general population and their relation to the risk of acute hospitalization and death. Serum levels of GDF15 were measured three times in 5-year intervals in 2176 participants aged 30, 40, 50, or 60 years from the Danish population-based DAN-MONICA cohort. We assessed the association of single and repeated GDF15 measurements with the risk of non-traumatic acute hospitalizations. We tested whether changes in GDF15 levels over 10 years differed according to the frequency of hospitalizations within 2 years or survival within 20 years, after the last GDF15 measurement. The change in GDF15 levels over time was dependent on age and sex. Higher GDF15 levels and a greater increase in GDF15 levels were associated with an increased risk of acute hospitalization in adjusted Cox regression analyses. Participants with more frequent admissions within 2 years, and those who died within 20 years, after the last GDF15 measurement already had elevated GDF15 levels at baseline and experienced greater increases in GDF15 levels during the study. The change in GDF15 levels was associated with changes in C-reactive protein and biomarkers of kidney, liver, and cardiac function. Monitoring of GDF15 starting in middle-aged could be valuable for the prediction of adverse health outcomes.

Healthcare Professionals' Perspective on Implementing a Detector of Behavioural Disturbances in Long-Term Care Homes

The number of Canadians with dementia is expected to rise to 674,000 in the years to come. Finding ways to monitor behavioural disturbance in patients with dementia (PwDs) is crucial. PwDs can unintentionally behave in ways that are harmful to them and the people around them, such as other residents or care providers. Current practice does not involve technology to monitor PwD behaviours. Events are reported randomly by nonstaff members or when a staff member notices the absence of a PwD from a scheduled event. This study aims to explore the potential of implementing a novel detector of behavioural disturbances (DBD) in long-term care homes by mapping the perceptions of healthcare professionals and family members about this technology. Qualitative information was gathered from a focus group involving eight healthcare professionals working in a tertiary care facility and a partner of a resident admitted in the same facility. Thematic analysis resulted in three themes: (A) the ability of the DBD to detect relevant dementia-related behavioural disturbances that are typical of PwD; (B) the characteristics of the DBD and clinical needs and preferences; (C) the integration of the DBD into daily routines. The results tend to confirm the adequacy of the DBD to the day-to-day needs for the detection of behavioural disturbances and hazardous behaviours. The DBD was considered to be useful and easy to use in the tertiary care facility examined in this study. The participants intend to use the DBD in the future, which means that it has a high degree of acceptance.

Effect of Behaviorally Designed Gamification With a Social Support Partner to Increase Mobility After Hospital Discharge: A Randomized Clinical Trial

IMPORTANCE

Hospitalization is associated with decreased mobility and functional decline. Behaviorally designed gamification can increase mobility in community settings but has not been tested among patients at risk for functional decline during a high-risk transition period after hospitalization.

OBJECTIVE

To test a behaviorally designed gamification intervention with a social support partner to increase patient mobility after hospital discharge.

DESIGN, SETTING, AND PARTICIPANTS

This study is a randomized clinical trial of a 12-week intervention without follow-up. Enrollment occurred from January 2018 to June 2019 at a referral hospital with a remote at-home monitoring intervention among patients living predominantly in 3 states (Pennsylvania, New Jersey, and Delaware). Participants included adult patients discharged from general medicine and oncology units to home. Data analysis was performed from October 2019 to March 2020.

INTERVENTIONS

All participants received a wearable device to track daily steps. The control group received feedback from the device but no other interventions. The intervention group entered into a 12-week game informed by behavioral economics to assign points and levels for achieving step goals and reinforced by a support partner who received updates on participant progress.

MAIN OUTCOMES AND MEASURES

The primary outcome was change in mean daily steps from baseline through the 12-week intervention. Secondary measures were change in functional status and urgent care utilization (ie, emergency department visits and hospital readmissions) within this period.

RESULTS

A total of 232 participants were enrolled in the study (118 randomized to control and 114 randomized to the intervention). Participants had a mean (SD) age of 40 (14) years, 141 (61%) were female, 101 (43%) were White, and 103 (44%) had an annual household income less than $50 000. Daily step counts increased from 3795 to 4652 steps (difference, 857 steps; 95% CI, 488 to 1224 steps) among intervention participants and increased from 3951 to 4499 steps (difference, 548 steps; 95% CI, 193 to 903 steps) among control participants. The change in mean daily step count from baseline was not significantly different for participants in the intervention group vs the control group (adjusted difference, 270 steps; 95% CI, -214 to 754 steps; P = .27). Among the subgroup of 76 participants with higher levels of social engagement, post hoc exploratory analyses showed a significant increase in mobility for intervention vs control (adjusted difference, 1125 steps; 95% CI, 409 to 1841 steps; P = .002). Fewer participants in this subgroup experienced functional decline (1 of 36 participants [4%] in the intervention group vs 5 of 40 participants [12%] in the control group) and hospital readmission at 30 days (3 of 36 participants [8%] in the intervention group vs 6 of 40 participants [15%] in the control group), but the differences were not statistically significant. There were no significant differences in these secondary outcomes for the overall sample.

CONCLUSIONS AND RELEVANCE

Gamification with social incentives did not affect mobility or functional decline in all participants, but post hoc analysis suggests positive findings for both outcomes for patients with higher social engagement.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03321279.

Frequency of But Not Capacity for Participation in Everyday Activities Is Associated With Cognitive Impairment in Late Life

We examined features of everyday activities (capacity and frequency) between older adults with and without cognitive impairment over 12 months. Participants aged ≥60 years and at risk for depression were included (n = 260); 26% (n = 69) had an acquired cognitive impairment at baseline. Cognitive impairment was defined as one standard deviation below norms on the Repeatable Battery for the Assessment of Neuropsychological Status. Features of everyday activities were measured by a computerized adaptive test version of Late-Life Function and Disability Instrument (LLFDI) at six time points (baseline, 6 weeks, 3, 6, 9, 12 months). There were significant between-group differences in activity frequency (p = .04), but not activity capacity (p = .05). The group difference in activity frequency exceeded minimal detectable changes (MDC₉₀ = 3.7) and reached moderate clinical meaningfulness (∆ at six time points = 3.7-4.7). Generalized linear mixed models revealed no Group × Time interactions on activity capacity and frequency (p = .65 and p = .98). Practitioners may assess changes in activity frequency to monitor cognitive status of clients even when there is no loss of activity capacity.

Evaluation of a Multisite Nurse-Led Mobility Plan

OBJECTIVE

The aim of this study was to examine the effect of nurses' mobility plan use on patients' length of stay, discharge destination, falls, physical therapy consults, and nurses' knowledge, attitudes, and beliefs regarding patient mobility.

BACKGROUND

Functional decline due to decreased mobility during hospitalization results in diminished quality of life. Sixty-five percent of older inpatients lose the ability to ambulate during hospitalization and 30% do not regain that capability.

METHODS

Using a quasi-experimental design, nurses' use of a mobility assessment on 4 patient outcome variables was examined before (n = 2,259) and after (n = 3,649) use. Nurses' attitudes, knowledge, and beliefs regarding mobility were also examined.

RESULTS

Positive changes in patient variables occurred. Limited change occurred relative to nurses' knowledge, attitudes, and beliefs.

CONCLUSIONS

Implementing a nurse-led mobility plan enhances therapy resource utilization through identification of appropriate consults and improves patients' discharge home. In addition, nurses' knowledge, attitudes, and beliefs toward patient mobility planning can be positively influenced.

The impact of frailty in older women undergoing pelvic floor reconstructive surgery

IMPORTANCE AND OBJECTIVE

Women ≥ 65 years old commonly undergo pelvic surgery but are often not screened for coexisting frailty, the presence of which increases the risk of postoperative complications. In the absence of a current consensus, the objective of this review is to discuss the incorporation of a frailty assessment into the work-up of women undergoing pelvic floor reconstructive surgery.

METHODS

This is a review of the literature, focusing on measurements of frailty including the Edmonton Frail Scale, FRAIL scale, Groningen Frailty Indicator, frailty phenotype, Tilburg Frailty Indicator, a 70-item frailty index, Mini-Cog score, Charlson comorbidity index, timed up and go test, and life-space assessment. Their use in the perioperative management of older women undergoing pelvic floor reconstructive surgery will be discussed.

DISCUSSION AND CONCLUSION

Understanding the concept of frailty and how it may affect surgical decisions and outcomes is essential. The timed up and go test, life space assessment and Mini-Cog assessment at a minimum should be considered preoperatively in patients over the age of 65 years old planning pelvic floor or elective surgery.

Increasing Life-Space Mobility in Community-Dwelling Older Persons With Cognitive Impairment Following Rehabilitation: A Randomized Controlled Trial

BACKGROUND

Community-dwelling older persons with cognitive impairment (CI) following discharge from geriatric rehabilitation are at high risk of losing life-space mobility (LSM). Interventions to improve their LSM are, however, still lacking. The aim of this study was to evaluate the effects of a CI-specific, home-based physical training and activity promotion program on LSM.

METHODS

Older persons with mild-to-moderate CI (Mini-Mental State Examination: 17-26 points) discharged home from rehabilitation were included in this double-blinded, randomized, placebo-controlled trial with a 12-week intervention period and 12-week follow-up period. The intervention group received a CI-specific, home-based strength, balance, and walking training supported by tailored motivational strategies. The control group received a placebo activity. LSM was evaluated by the Life-Space Assessment in Persons with Cognitive Impairment, including a composite score for LSM and 3 subscores for maximal, equipment-assisted, and independent life space. Mixed-model repeated-measures analyses were used.

RESULTS

One hundred eighteen participants (82.3 ± 6.0 years) with CI (Mini-Mental State Examination: 23.3 ± 2.4) were randomized. After the intervention, the home-based training program resulted in a significant benefit in the Life-Space Assessment in Persons with Cognitive Impairment composite scores (b = 8.15; 95% confidence interval: 2.89-13.41; p = .003) and independent life-space subscores (b = 0.39; 95% confidence interval: 0.00-0.78; p = .048) in the intervention group (n = 63) compared to control group (n = 55). Other subscores and follow-up results were not significantly different.

CONCLUSIONS

The home-based training program improved LSM and independent life space significantly in this vulnerable population. Effects were not sustained over the follow-up. The program may represent a model for improved transition from rehabilitation to the community to prevent high risk of LSM restriction.

Neighborhood Participation Is Less Likely among Older Adults with Sidewalk Problems

Objectives: This cross-sectional study examines the association between perceived sidewalk conditions and neighborhood participation among older adults in the REasons for Geographic and Racial Differences in Stroke (REGARDS) study. Methods: Between 2013-2016, 14,233 REGARDS participants completed a second in-home visit. Using logistic regression, we cross-sectionally examined if perceived severity of sidewalk problems was associated with going into the neighborhood less than once compared to 1-7 times per week. Results: The analytic sample included participants (N = 9863) with nonmissing data. The likelihood of going into the neighborhood less than one time per week was greater among participants who reported minor (OR = 1.15; 95% CI: 1.00, 1.33), somewhat serious (OR = 1.41; 95% CI: 1.17, 1.70), and very serious (OR = 1.65; 95% CI: 1.38, 1.98) sidewalk problems in their neighborhood compared to those reporting no sidewalk problems, independent of demographic, socioeconomic, and impairment characteristics. Discussion: Perceived sidewalk problems appear to deter neighborhood participation among older adults.

Life-Space Mobility in the Elderly: Current Perspectives

Life-space mobility (LSM) is a concept for assessing patterns of functional mobility over time. LSM is gaining traction in the research of geriatric population health. Several instruments have been developed to measure LSM, such as the University of Alabama at Birmingham Life-Space Assessment (LSA) or the Nursing Home Life-Space Diameter instrument. There has been exponential growth in the use of instruments measuring LSM in studies of older adults since the concept was introduced in 1985. In response to the increased volume of publications with clinical applicability to those working in geriatric health or conducting population-based research in older adults, we conducted a narrative review: a) to provide a summary of the articles that have assessed validation of the University of Alabama at Birmingham LSA instrument, the most widely used instrument to assess LSM in older adults; and b) to provide a summary of the research articles that have examined LSM as independent or outcome variable. Studies for this review were obtained with an organized search format and were included if they were published in the past 20 years, written in English, published in peer-reviewed literature, and included LSM as an independent or outcome variable. Seventy-nine articles were identified: 36 that employed a cross-sectional design and 22 that employed a longitudinal/prospective design to examine LSM as outcome variable; 17 longitudinal/prospective design articles that examined LSM as primary independent variable; 3 review articles; and 1 systematic review. Areas of research included physical function, cognitive function, sensory impairment, mental health, falls, frailty, comorbidities, healthcare use, mortality, and social/environmental factors. These studies showed that LSM instruments can accurately predict morbidity, mortality, and healthcare use.

Promoting physical activity in geriatric patients with cognitive impairment after discharge from ward-rehabilitation: a feasibility study

The aim of the present study was to examine adherence and acceptance of a home-based program to promote physical activity (PA) in older persons with cognitive impairment (CI) following inpatient rehabilitation. Sixty-three older persons (≥ 65 years) with mild to moderate CI (Mini-Mental State Examination score 17-26), allocated to the intervention group of a randomized, controlled intervention trial underwent a 12-week home-based PA intervention including (1) physical training and outdoor walking to improve functional fitness and (2) motivational strategies (goal-setting, pedometer-based self-monitoring, social support delivered by home visits, phone calls) to promote PA. Training logs were used to assess adherence to physical training, outdoor walking and to motivational strategies (goal-setting, pedometer-based self-monitoring). Acceptance (subjective feasibility and effectiveness) of the program components was assessed by a standardized questionnaire. Mean adherence rates over the intervention period were 63.6% for physical training, 57.9% for outdoor walking, and between 40.1% (achievement of walking goals), and 60.1% (pedometer-based self-monitoring) for motivational strategies. Adherence rates significantly declined from baseline to the end of intervention (T1: 43.4-76.8%, T2: 36.1-51.5%, p values<.019). Most participants rated physical training, outdoor walking, goal-setting, and pedometer self-monitoring as feasible (68.2-83.0%) and effective (63.5-78.3%). Highest ratings of self-perceived effectiveness were found for home visits (90.6%) and phone calls (79.2%). The moderate to high adherence to self-performed physical training and motivational strategies proved the feasibility of the home-based PA program in older persons with CI following inpatient rehabilitation.

Reliability and Concurrent Validity of Life Space Assessment in Individuals With Vestibular Disorders

BACKGROUND AND PURPOSE

The Life Space Assessment (LSA) is a self-report measure that allows clinicians to determine how often someone moves around in his or her environment with or without assistance. Presently, there are no reliable and valid measures that capture all 3 aspects of mobility (ie, mobility frequency, distance, and assistance needed) for individuals with vestibular disorders. The purpose of this study was to describe life space and to determine the reliability and concurrent validity of the LSA as a tool to measure mobility and function in individuals with balance and vestibular disorders.

METHODS

One hundred twenty-eight participants (mean age of 55 ± 16.7 years) experiencing dizziness or imbalance who were seeking the care of an otoneurologist were recruited. Participants completed the LSA, Dizziness Handicap Inventory (DHI), and the 12-Item Short Form Health Survey (SF-12).

RESULTS

The mean LSA score of the sample was 75/120 ± 30. The LSA demonstrated excellent test-retest reliability (intraclass correlation coefficient = 0.91). The LSA was negatively correlated with the DHI total score (ρ = -0.326, P < 0.01), DHI physical subscore (ρ = -0.229, P = 0.02), DHI functional subscore (ρ = -0.406, P < 0.01), and DHI emotional subscore (ρ = -0.282, P < 0.01). The LSA was positively correlated with both the physical (ρ = 0.422, P < 0.01) and mental (ρ = 0.362, P < 0.01) composite scores of the SF-12.

DISCUSSION AND CONCLUSIONS

Similar to the findings in community-dwelling older adults, the LSA demonstrated excellent test-retest and internal consistency in individuals with vestibular disorders. The LSA is a valid and reliable tool for measuring mobility and function in individuals with vestibular disorders.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A317).

Mobility Limitation After Surgery for Degenerative Pathology of the Ankle, Hindfoot, and Midfoot vs Total Hip Arthroplasty

BACKGROUND

Surgery for degenerative foot and ankle conditions often results in a lengthy recovery. Current outcome measures do not accurately assess postoperative mobility, especially in older patients. The Life-Space Assessment (LSA), a questionnaire quantifying patients' mobility after a medical event, was used in this study to assess perioperative mobility in total hip arthroplasty (THA) and foot and ankle surgery patients. We hypothesized that patients undergoing elective foot and ankle surgery would have greater postoperative mobility limitation than THA patients.

METHODS

Preoperative, 3-month, and 6-month postoperative LSA data were collected from THA and foot and ankle cohorts. Twelve-month postoperative data were obtained for the foot and ankle group as well. Patient demographics were recorded, and data were analyzed using a Mann-Whitney U test.

RESULTS

Twenty-eight degenerative foot and ankle operative patients and 38 THA patients met inclusion criteria. Only patients aged ≥60 years were included in this study. The mean preoperative LSA score was lower in the foot and ankle group (68.8) compared with THA (74.0), although the difference was not statistically significant (P = .602). THA patients showed a significant increase in LSA score from preoperative (74) to 6 months postoperation (95.9) (P = .003); however, foot and ankle patients showed no significant difference between preoperative (68.8) and 6-month (61.2) scores (P = .468). Twelve months postoperatively, foot and ankle patients showed improvement in LSA score (88.3) compared with preoperation (P = .065).

CONCLUSION

Compared with THA, recovery of mobility after foot and ankle surgery was slower. THA patients exhibited improved mobility as early as 3 months after surgery, whereas foot and ankle patients did not show full improvement until 12 months. This work will assist the foot and ankle specialist in educating patients about challenges in mobility during their recovery from surgery.

LEVEL OF EVIDENCE

Level II, prospective cohort study.

Association of peripheral artery disease with life-space mobility restriction and mortality in community-dwelling older adults

OBJECTIVE

Symptomatic peripheral artery disease (PAD) impairs walking, but data on the impact of PAD on community mobility is limited. Life-space mobility measures the distance, frequency, and assistance needed as older adults move through geographic areas extending from their bedroom (life-space mobility score: 0) to beyond their town (life-space mobility score: 120). We evaluated the association of PAD with longitudinal life-space mobility trajectory.

METHODS

Participants were part of the University of Alabama at Birmingham Study of Aging, a longitudinal study of community-dwelling older adults who were observed from 2001 to 2009. We limited our analysis to those who survived at least 6 months (N = 981). PAD was based on self-report with verification by physician report and hospital records. Our primary outcome was life-space mobility score assessed every 6 months. A multilevel change model (mixed model) was used to determine the association between PAD and life-space mobility trajectory during a median 7.9 years of follow-up.

RESULTS

Participants had a mean age of 75.7 (standard deviation, 6.7) years; 50.5% were female, and 50.4% were African American. PAD prevalence was 10.1%, and 57.1% of participants with PAD died. In participants with both PAD and life-space restriction, defined as life-space mobility score <60, we observed the highest mortality (73.1%). In a multivariable adjusted mixed effects model, participants with PAD had a more rapid decline in life-space mobility by -1.1 (95% confidence interval [CI], -1.9 to -0.24) points per year compared with those without PAD. At 5-year follow-up, model-adjusted mean life-space mobility was 48.1 (95% CI, 43.5-52.7) and 52.4 (95% CI, 50.9-53.8) among those with and without PAD, respectively, corresponding to a restriction in independent life-space mobility at the level of one's neighborhood.

CONCLUSIONS

Life-space mobility is a novel patient-centered measure of community mobility, and PAD is associated with significant life-space mobility decline among community-dwelling older adults. Further study is needed to mechanistically confirm these findings and to determine whether better recognition and treatment of PAD alter the trajectory of life-space mobility.

Disability and Recovery After Hospitalization for Medical Illness Among Community-Living Older Persons: A Prospective Cohort Study

OBJECTIVES

To determine for each basic, instrumental, and mobility activity after hospitalization for acute medical illness: (1) disability prevalence immediately before and monthly for 6 months after hospitalization; (2) disability incidence 1 month after hospitalization; and (3) recovery time from incident disability during months 2 to 6 after hospitalization.

DESIGN

Prospective cohort study.

SETTING

New Haven, Connecticut.

PARTICIPANTS

A total of 515 community-living persons, mean age 82.7 years, hospitalized for acute noncritical medical illness and alive within 1 month of hospital discharge.

MEASUREMENTS

Disability was defined monthly for each basic (bathing, dressing, walking, transferring), instrumental (shopping, housework, meal preparation, taking medications, managing finances), and mobility activity (walking a quarter mile, climbing flight of stairs, lifting/carrying 10 pounds, driving) if help was needed to perform the activity or if a car was not driven in the prior month.

RESULTS

Disability was common 1 and 6 months after hospitalization for activities frequently involved in leaving the home to access care including walking a quarter mile (prevalence 65% and 53%, respectively) and driving (65% and 61%). Disability was also common for activities involved in self-managing chronic health conditions including meal preparation (53% and 41%) and taking medications (41% and 31%). New disability was common and often prolonged. For example, 43% had new disability walking a quarter mile, and 30% had new disability taking medications, with mean recovery time of 1.9 months and 1.7 months, respectively. Findings were similar for the subgroup of persons residing at home (ie, not in a nursing home) at the first monthly follow-up interview after hospitalization.

CONCLUSION

Disability in specific functional activities important to leaving home to access care and self-managing health conditions is common, often new, and present for prolonged time periods after hospitalization for acute medical illness. Post-discharge care should support patients through extended periods of vulnerability beyond the immediate transitional period. J Am Geriatr Soc 68:486-495, 2020.

Validation of the Hendrich II Fall Risk Model: The imperative to reduce modifiable risk factors

AIM

To validate the psychometrics of the Hendrich II Fall Risk Model (HIIFRM) and identify the prevalence of intrinsic fall risk factors in a diverse, multisite population.

BACKGROUND

Injurious inpatient falls are common events, and hospitals have implemented programs to achieve "zero" inpatient falls.

METHODS

Retrospective analysis of patient data from electronic health records at nine hospitals that are part of Ascension. Participants were adult inpatients (N = 214,358) consecutively admitted to the study hospitals from January 2016 through December 2018. Fall risk was assessed using the HIIFRM on admission and one time or more per nursing shift.

RESULTS

Overall fall rate was 0.29%. At the standard threshold of HIIFRM score ≥ 5, 492 falls and 76,800 non-falls were identified (fall rate 0.36%; HIIFRM specificity 64.07%, sensitivity 78.72%). Area under the receiver operating characteristic curve was 0.765 (standard error 0.008; 95% confidence interval 0.748, 0.781; p < 0.001), indicating moderate accuracy of the HIIFRM to predict falls. At a lower cut-off score of ≥4, an additional 74 falls could have been identified, with an improvement in sensitivity (90.56%) and reduction in specificity (44.43%).

CONCLUSION

Analysis of this very large inpatient sample confirmed the strong psychometric characteristics of the HIIFRM. The study also identified a large number of inpatients with multiple fall risk factors (n = 77,292), which are typically not actively managed during hospitalization, leaving patients at risk in the hospital and after discharge. This finding represents an opportunity to reduce injurious falls through the active management of modifiable risk factors.

Hospitalized Adult Patient Characteristics Associated With Participation in a Volunteer-Assisted Mobility Program: A Feasibility Study

BACKGROUND

Physical inactivity during hospitalization commonly results in functional decline. Structured multidisciplinary programs/approaches may be useful to promote mobility in hospitalized adults.

PURPOSE

The purpose was to determine whether a volunteer-assisted mobility program was feasible to improve the ambulation of hospitalized patients, and examine the characteristics of patients associated with willingness to participate in the program.

METHODS

A prospective descriptive correlation study was conducted in 2 acute care units. A volunteer-staffed program was implemented with the aim of improving the ambulation of hospitalized patients.

RESULTS

Hospitalized patients (N = 490) were approached, with 39.2% (n = 192) agreeing to ambulate an average of 109.7 m (interquartile range = 51.45-172.2 m). Patients with a low clinical frailty score, high body mass index, or physical therapy order were more likely to participate in the volunteer-assisted mobility program.

CONCLUSIONS

The findings suggest that a volunteer-assisted interdisciplinary program is a feasible way to promote the ambulation of some patients.

Activities of Daily Living and Life-Space Mobility in Older Adults with Chronic Obstructive Pulmonary Disease

Purpose

The aim of this study was to investigate whether limitation during the performance of activities of daily living (ADL) was associated with life-space mobility in older people with chronic obstructive pulmonary disease (COPD), and to generate a regression model for life-space mobility score.

Patients and Methods

This cross-sectional study with a convenience sample included older people (aged ≥60 years old) with COPD. We assessed participants’ lung function (spirometry), life-space mobility (University of Alabama at Birmingham Study of Aging Life-Space Assessment questionnaire), severity of dyspnea (Modified Dyspnea Index) and limitation during the performance of ADL (London Chest Activity of Daily Living). We used Pearson’s correlation to investigate the associations between the measures, and multiple linear regression to detect which of the measures influenced life-space mobility. Statistical significance was set at 5%.

Results

Fifty participants completed all the assessments (29 females [58%]; mean ± SD age of 67 ± 6 years old, FEV₁ 47 ± 29% of predicted, and body mass index 22.5 ± 11.6 kg/m²). Their mean scores for life-space mobility and for limitation during the performance of ADL were 49.7 ± 27.2 and 16.46 ± 9.74, respectively. We found a strong inverse correlation between limitation during the performance of ADL and life-space mobility (r = −0.57, p = <0.01) as well as between severity of dyspnea and life-space mobility (r= 0.86, p= <0.01). Both sex and limitation during the performance of ADL were considered as independent factors associated to life-space mobility (R²= 0.56).

Conclusion

In this study, limitations during the performance of ADL and dyspnea had a strong correlation with life-space mobility in older adults with COPD. Also, alongside sex, the limitation during the performance of ADL is an independent factor associated with life-space mobility in a regression model.

Feasibility of low-cost accelerometers in measuring functional recovery after major oncologic surgery

BACKGROUND AND OBJECTIVES

Low-cost consumer-based activity monitors (CAMs), such as the Fitbit, are popular for fitness and wellness tracking. Functional status is an excellent predictor of postoperative outcomes, yet objective measurements are resource-intensive. The aim of this study is to demonstrate the feasibility of using activity monitors during the perioperative period in patients undergoing major oncologic surgery.

METHODS

An institution review board proved that a prospective study was conducted. CAMs were worn throughout the perioperative period and accelerometer data were collected. Baseline and 21-days follow-up functional measures included short physical performance battery, Community Health Activities Model Program questionnaire, mobility assessment tool-short form, and 400 m walk.

RESULTS

A total of 19 of 22 (86%) patients who wore a CAM during the perioperative period had analyzable data. Compliance with wearing the device varied significantly: 100% preadmission, 19% in-hospital, and 82% postdischarge. Median daily steps decreased from preadmission to postdischarge (77% median reduction). Established resource-intensive measures of functional status did not perform well as measures of decreased functional status and activity when comparing baseline to 21-day postdischarge assessments.

CONCLUSIONS

Activity monitors are a feasible, low-cost measure of perioperative activity for patients undergoing major surgery, and may be useful in identifying patients vulnerable to postsurgical complications.

Use of tracking technology to examine life-space mobility among people with depression: a systematic review protocol

INTRODUCTION

People with depression often experience disabilities that limit their social and physical capacity, daily function, and quality of life. Depressive symptoms and their implications on daily activities are often measured retrospectively using subjective measurement tools. Recently, more objective and accurate electronic data collection methods have been used to describe the daily life of people with depressive disorders. The results, however, have not yet been systematically reviewed. We aim to provide a knowledge basis for the use of tracking technologies in examining life-space mobility among adults with depression and those with anxiety as a comorbidity.

METHODS AND ANALYSIS

A systematic review with a narrative approach for different types of study design will be conducted. The following databases will be used to gather data from 1994 to the present: MEDLINE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Embase, Cochrane Library, Scopus, Web of Science, Health Technology Assessment Database and IEEE Xplore. The study selection will follow the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. Methodological appraisal of studies will be performed using the Crowe Critical Appraisal Tool as well as the Cochrane Risk-of-Bias Tool for randomised controlled trials. A narrative synthesis of all included studies will be conducted.

ETHICS AND DISSEMINATION

Because there will be no human involvement in the actual systematic review, no ethical approval will be required. The results will be disseminated in a peer-reviewed journal and in a conference presentation.

PROSPERO REGISTRATION NUMBER

CRD42019127102.