Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

An in-hospital program for acutely ill elderly promoted independence at discharge

ACP J Club. 1995 Nov-Dec;123:69. doi:10.7326/ACPJC-1995-123-3-069


Source Citation

Landefeld CS, Palmer RM, Kresevic DM, Fortinsky RH, Kowal J. A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. N Engl J Med. 1995 May 18;332:1338-44.


Abstract

Objective

To evaluate an in-hospital program designed to improve performance of activities of daily living (ADL) of older patients with acute illness.

Design

Randomized controlled trial.

Setting

General medicine unit of a U.S. university-affiliated teaching hospital.

Patients

651 patients (mean age 80 y, 67% women) who were ≥ 70 years of age and were admitted for general medical care. Patients in specialty units were ineligible. Follow-up (99%) was until death or 3 months after hospital discharge.

Intervention

Patients were allocated to the Acute Care for Elders program (n = 327) or to a usual care group (n = 324). Features of the acute care program included a prepared environment (carpeting, handrails, clear hallways, large clocks), patient-centered care (promotion of independence and self-care), formal discharge planning (home care needs), and medical care review (minimization of adverse effects of prescribed procedures and medications). Usual care was provided by physicians and nurses in separate general medicine units.

Main outcome measures

Change from admission to discharge in performance of basic and instrumental ADL, discharge destination, and overall health status, assessed by unblinded interviews and medical records.

Main results

24 patients in each group died in the hospital. At hospital discharge, 21% of the 303 intervention group patients who survived were classified as much better in their ability to do ADL, 13% as better, 50% as unchanged, 7% as worse, and 9% as much worse. Of the 300 usual care group patients who survived, 13% were classified as much better, 11% as better, 54% as unchanged, 13% as worse, and 8% as much worse (P = 0.009 for the linear trend). Intervention group patients could do more basic ADLs than the usual care group patients (mean number of ADLs 3.6 vs 3.3, P = 0.05). Patients in the intervention group had better overall health status at discharge than patients in the usual care group (P < 0.001). 14% of the intervention group patients were discharged to a long-term care institution compared with 22% of the usual care group patients (P = 0.01). 3 months after discharge, the groups no longer differed for independent ADLs or overall health status. Length of stay and hospital charges were similar in the 2 groups.

Conclusions

An in-hospital program of specialized care for older patients improved performance of activities of daily living and decreased nursing home placement. The increased performance was not sustained 3 months after discharge.

Sources of funding: John A. Hartford Foundation and National Institute on Aging.

For article reprint: Not available.


Commentary

For many older persons, hospitalization is the first step toward loss of independence and institutionalization (1). Inpatient geriatric units are designed to combat these negative effects with multidisciplinary comprehensive assessment and attention to function and rehabilitation. Although randomized trials have shown that these units improve function and decrease nursing home use in carefully selected patients, patients often enter geriatric units only after the resolution of an acute illness, which may result in a lengthy inpatient stay and increased hospital costs (2, 3). The randomized trial by Landefeld and colleagues is the first to show the effectiveness of an acute inpatient geriatric unit for an unselected group of elderly medical patients, without increasing either the length or cost of hospitalization. An economic analysis of this trial published in 1997 (4) shows that the geriatric unit was not more expensive than usual care.

The interventions used deserve highlighting because they include practices that could be managed on any medical ward, such as reviewing medications for drug interactions, encouraging mobility and independence, avoiding restraints, assessing psychosocial needs, and instituting guidelines for the management of common geriatric problems (e.g., incontinence, falls, and decline in mental status) (5).

This study was well designed and adds to the evidence supporting the effectiveness of inpatient geriatric units. Even so, two thirds of the intervention group either did not improve or experienced a functional decline, and positive effects were not sustained after discharge. Targeting patients most likely to benefit from specialized care and adding an outpatient component might increase the effectiveness of this intervention. Although this model shows promise, it should be replicated and refined in multicenter trials before being widely adopted.

Carol Joseph, MD
Department of Veterans Affairs Medical CenterPortland, Oregon, USA


References

1. Creditor MC. Hazards of hospitalization of the elderly. Ann Intern Med. 1993;118:219-23.

2. Rubenstein LZ, Josephson KR, Wieland GD, et al. Effectiveness of a geriatric evaluation unit. A randomized clinical trial. N Engl J Med. 1984;311:1664-70.

3. Applegate WB, Miller ST, Graney MJ, et al. A randomized, controlled trial of a geriatric assessment unit in a community rehabilitation hospital. N Engl J Med. 1990;322:1572-8.

4. Covinsky KE, King JT Jr, Quinn LM, et al. Do acute care for elders units increase hospital costs? A cost analysis using the hospital perspective. J Am Geriatr Soc. 1997;45:729-345.

5. Palmer RM, Landefeld CS, Kresevic D, Kowal J. A medical unit for the acute care of the elderly. J Am Geriatr Soc. 1994;42:545-52.