Activity of daily living trajectories surrounding acute hospitalization of long-stay nursing home residents

Abstract

Objectives: To explore patterns of change in nursing home (NH) residents' activities of daily living (ADLs), particularly surrounding acute hospital stays.

Design: Longitudinal study using Medicare and Minimum Data Set (MDS) assessments.

Setting: National sample of long-stay NH residents.

Participants: NH residents who were hospitalized for the seven most-common inpatient diagnoses (N = 40,128). Each hospital admission was at least 90 days after any prior hospitalization and had at least two preceding MDS assessments.

Measurements: The MDS ADL long-form score, a simple sum of seven self-care variables coded from 0 (independent) to 4 (totally dependent) was used to indicate resident ADL function. Scores ranged from 0 to 28, with higher scores indicating greater impairment. A linear mixed model describing ADL trajectories was jointly estimated with time-to-event models for mortality and hospital readmission.

Results: Before hospitalization, the most common trajectory was stable (53.7%), with 27.5% of residents worsening and 18.8% improving. ADL function after hospital discharge was most often characterized as stable (43.1%) or worsening (39.2%). Mortality (20.3%) was higher for those with worsening prehospital ADL function (28.9%) than for those with stable (19.1%) or improving (11.3%) trajectories. Hospital diagnosis was associated with amount of ADL worsening and rate of subsequent ADL change. Most residents with the best initial function continued to worsen after hospital discharge. Cognitive impairment was associated with poorer ADL function and accelerated worsening of ADLs.

Conclusion: For many long-stay NH residents, substantial and sustained ADL worsening accompanies acute hospitalization, so acute hospitalization presents an opportunity to revisit care goals; the results of the current study can help inform decision-making.

Keywords: Minimum Data Set; activities of daily living; hospitalization; nursing homes.

Figure 1

Flow diagram showing derivation of cohort of long-stay nursing home residents. MDS = Minimum Data Set ADL = activities of daily living HMO = health maintenance organization

Figure 2

Average ADL trajectories predicted by regression model (Table 3a) for nursing home residents hospitalized for hip fracture or pneumonia. Because the primary hospital diagnosis is not present before the acute event, the pre-hospital trajectory is identical for the two diagnoses. The slow pre-hospital worsening in ADL function is followed by precipitous worsening surrounding the acute hospitalization. The amount of worsening varies by diagnosis and is equal to the intercepts in Table 3a – hip fracture was associated with a 7.65-point change and pneumonia was associated with a 2.74-point change. On average, hip fracture patients improve following hospital discharge while residents hospitalized for pneumonia (and the other diagnoses) continue to worsen. For purposes of illustration, the modal characteristics of the population were used for other resident characteristics: age > 85, female, moderately impaired cognition (Cognitive Performance Scale=3), moderate baseline ADL impairment (baseline ADL 5–23), Charlson Comorbidity Index=2, and hospital length of stay=5 days. ADL = activities of daily living