Critically Appraised Topic 2014

Author: Stephanie Coenen
Created on: August 18th
, 2014 Kill or update by: August 18th
, 2016

University
of
Wisconsin-‐Milwaukee

Doctor
of
Physical
Therapy
Program

The
Affect
of
Low
Mobility
on
Hospitalized
Older
Adult’s
Functional
Level

Introduction:

3
Part
Clinical
Question:

Search
Terms:

For
older
adults
aged
65+
years
old
that
are
hospitalized,
does
low
mobility
have
a
negative
effect
on
patient’s
functional
level
at
time
of
discharge?

For
purposes
of
this
Critically
Appraised
Topic,
“low
mobility”
can
be
defined
as
total
bed
rest
or
transferring
from
bed
to
chair
or
commode
twice
a
day,

which
reflects
that
most
hours
of
the
day
are
spent
laying
or
sitting.

a)
Geriatrics
OR
elderly
OR
“older
adult,”

b)
Mobility,

c)
"Functional
recovery"
OR
“functional
decline,”

d)
Surgery
OR
hospitalization,

e)
Combination
of
a,
b,
c,
AND
d

• Search
engine
used:
UW-‐Milwaukee
Libraries,
http://uwm.edu/libraries/

• Inclusion
criteria:
inpatient
setting,
participants
aged
65+
years,
defined
mobility

• Exclusion
criteria:
articles
published
before
2000,
case
studies

Community
dwelling
older
adults
are
often
sedentary
and
do
not
get
the
suggested
30
minutes
per
day
of
physical
activity
as
recommended
by
the
Center
for

Disease
Control
3
.

Furthermore,
hospitalization
of
the
previously
healthy
older
adult
has
been
associated
with
significant
decreases
in
muscle
mass
and

strength
2
,
and
increased
rates
of
functional
disability
with
an
increased
likelihood
of
nursing
home
placement
at
time
of
discharge
1
.

The
combination
of
these

factors
has
the
potential
to
negatively
affect
an
older
adult’s
functional
status
after
hospitalization.

The
purpose
of
this
research
project
is
to
determine
if

low
mobility
during
hospitalization
has
been
shown
to
decrease
an
older
adult’s
functional
level
at
the
time
of
discharge
from
the
hospital.

, 2016
Participant
and
Study
Characteristics:

Reference

Participant
Key
Clinical

Characteristics

Control
Intervention

(frequency/duration)

Experimental
Intervention

(frequency/duration)

Level
of

Evidence

Cook,
D.,
Thompson,

J.,
Prinsen,
S.,

Dearani,
J.,
&

Deschamps,
C.

(2013).
Functional

Recovery
in
the

Elderly
After
Major

Surgery:
Assessment

of
Mobility
Recovery

Using
Wireless

Technology.
The

Annals
of
Thoracic

Surgery,
1057-‐1061.

− Age:
68.0
+/-‐
9.0
years
old,

ranging
from
52
–
90
years

− Sex:
66%
male,
34%
female

− Primary
medial
diagnoses:

hypertension
65%,
A-‐fib
21%,

diabetes
17%,
sleep
apnea
16%,

anticoagulation
14%,
renal

insufficiency
5%,
pulmonary

hypertension
4%

− Surgical
received:
valve
43%,

CABG
32%,
valve
and
CABG

14%,
septal
myectomy
5%,

ascending
aortic
aneurysm
4%,

other
1%

− Other
requirements:
elective

surgery,
expected
hospital
stay

5-‐7
days,
lived
at
home,
able
to

ambulate
before
surgery

N/A
− 149
surgical
patients
received
a

wireless
accelerometer
fitted
on

an
ankle
strap
to
monitor
steps

taken
throughout
the
day

(which
defined
mobility)
until

discharged
from
the
hospital

− Length
of
stay
(LOS)
in
the

hospital
and
discharge
location

was
recorded

− The
study’s
intent
was
to

determine
whether

postoperative
mobility
could
be

measured
wirelessly
in
a

hospitalized
elderly
population,

and
secondarily
to
examine
the

relationship
between
mobility

and
hospital
LOS

Level
4-‐

Prospective

Cohort
Study

Zisberg,
A.,
Shadmi,

E.,
Sinoff,
G.,
Gur-‐
Yaish,
N.,
Srulovici,

E.,
&
Admi,
H.

(2011).
Low
Mobility

During

Hospitalization
and

Functional
Decline
in

Older
Adults.

Journal
of
the

American
Geriatrics

Society,
59(2),
266-‐
273.
Retrieved
July

21,
2014.

− Age:
78.3
+/-‐
6.0
years
old

− Sex:
49.5%
female,
50.5%
male

− Admitted
to
hospital:
8.7%
from

a
nursing
home
or
living
with
a

paid
caregiver,
91.3%
were

independent
community

dwellers

− Exclusions:
completely

dependent
at
baseline,
those

who
were
admitted
with

cerebrovascular
disease,
coma,

or
mechanical
ventilation,

elective
hospitalizations,
unable

to
communicate,
hospital
LOS

was
less
than
2
days,
decreased

N/A
− 252
patients
in
the
hospital
were

eligible
and
participated
in
the

study

− A
baseline
interview
was

conducted,
which
included
items

on
demographic
data,
living

conditions,
and
self-‐assessment

of
functional
status
using
the

modified
Barthel
Index
(BI)
for

activities
of
daily
living
(ADLs)

and
the
Lawton
and
Brody’s

scale
for
instrumental
activities

of
daily
living
(IADLs),
and
an

assessment
of
level
of
mobility

Level
4-‐

Prospective

Cohort
Study

, 2016
cognitive
status
(as
determined

by
Short
Portable
Mental
Status

Questionnaire,
and
those
who

refused
to
participate
or
died

during
hospitalization

during
the
month
before

admission
using
the
Yale

Physical
Activity
Survey
(YPAS)

− Hospital
mobility
levels
were

assess
through
daily
interviews

with
the
participant
using
a

modification
of
a
mobility
index

developed
in
a
previous
study,

which
determined
the
frequency

of
all
mobility
efforts
of
any
type

(physical
therapy
[PT],
initiated

by
others,
or
self-‐initiated)
in
the

previous
24-‐hr
period

• Score
ranged
0
–
14

• Scores
were
categorized

into
three
mobility
groups:

low
(total
bed
rest
or

transferring
from
bed
to

chair
up
to
twice
a
day),

moderate
(ambulation

inside
the
room
only),
and

high
(ambulation
at
least

once
a
day
outside
the

room,
in
addition
to

mobility
inside
the
room)

− Medical
records
were
extracted

to
determine
admission
details

and
discharge
destination
or

death

− Discharge
interviews
assessed

participants’
current
ability
to

perform
ADLs
using
the
BI

− One-‐month
follow-‐up
interviews

assessing
ADL
and
IADL
abilities

were
conducted
via
phone

interview

, 2016
Brown,
C.,
Redden,

D.,
Flood,
K.,
&

Allman,
R.
(2009).

The

Underrecognized

Epidemic
of
Low

Mobility
During

Hospitalization
of

Older
Adults.

Journal
of
the

American
Geriatrics

Society,
57(9),
1660-‐
1665.
Retrieved
July

21,
2014.

− Age:
74.2
=/-‐
6.5
years
old

− Sex:
100%
male

− Married:
46.7%
(n=21)

− Exclusions:
delirium
(as

assessed
by
the
Confusion

Assessment
Method),
dementia

(as
assessed
by
the
Mini
Mental

State
Exam),
inability
to
walk
in

the
2
weeks
before
admission

needing,
requiring
isolation

precautions,
and
having
a

surgical
(vs.
medical)
reason
for

admission

− Received
PT
during

hospitalization:
33.3%
(n=15)

− Admission
physician
orders
for

bed
rest:
8.9%
(n=4),
although

not
retained
throughout

hospital
stay

N/A
− 45
male
patients
in
the
hospital

were
eligible
and
participated
in

the
study

− Wireless
accelerometers
were

attached
to
the
thigh
and
ankle

of
patients
for
the
first
7
days

after
admission
or
until
hospital

discharge
whichever
came
first

− The
mean
proportion
of
time

spent
lying,
sitting,
and
standing

or
walking
was
determined
for

each
hour
after
hospital

admission
using
a
previously

validated
algorithm
(Brown,

2004)
Level
4-‐

Prospective,

Observational

Cohort
Study

Brown,
C.,
Friedkin,

R.,
&
Inouye,
S.

(2004).
Prevalence

and
Outcomes
of

Low
Mobility
in

Hospitalized
Older

Patients.
Journal
of

the
American

Geriatrics
Society,

52(8),
1263-‐1270.

Retrieved
August
17,

2014.

− Age:
78.7
+/-‐
6.1
years
old

− Sex:
44%
male,
56%
female

− Married:
46%
(n=230)

− Living
alone:
33%
(n=164)

− Dementia
diagnosis:
17%
(n=83)

− Carlson
Comorbidity
Index

score
upon
admission:
2.9
+/-‐

2.2

− ADL
impairment
upon

admission:
19%
(n=93)

N/A
− 489
patients
in
the
hospital
were

eligible
and
participated
in
the

study

− The
baseline
patient
interview

included
demographics,
self-‐
reported
physical
function
2

weeks
before
admission,
12
and

the
Mini-‐Mental
State

Examination

− The
baseline
nurse
interview

included
a
rating
for
basic
ADLs

(independent,
required
some

assistance,
or
required
total

assistance)
upon
hospital

admission

− The
family
interview
included

the
modified
Blessed
Dementia

Level
4-‐

Prospective

Cohort
Study

, 2016
Rating
Scale
to
evaluate
for
the

presence
of
dementia
at

baseline

− Medical
records
were
extracted

to
determine
admission
details

and
discharge
destination
or

death

− Primary
nurses
were

interviewed
and
asked
to
rate

the
patients’
ADLs
and
mobility

of
any
type
(PT,
initiated
by

others,
or
self-‐initiated)
in
the

previous
24-‐hour
period

− An
empiric
scoring
system
was

developed,
assigning
points

from
0
to
12
for
increasing
levels

of
mobility,
as
follows:
Bedrest

was
assigned
a
score
of
0;

transferring
from
bed
to
chair

once
was
assigned
a
score
of
2;

transferring
2
or
more
times,
a

score
of
4;
ambulation
once
with

total
assistance
was
assigned
a

score
of
6;
two
or
more
times

with
total
assistance
or
once

with
partial
or
no
assistance,
a

score
of
8;
two
or
more
times

with
partial
assistance,
a
score

of
10;
and
independent

ambulation
two
or
more
times

per
day,
a
score
of
12

− Three
mobility
groups
were

identified:
high
(score
>8),

intermediate
(score
4-‐8),
and

low
(score
<4)

− The
primary
outcome
was

functional
decline
during

, 2016
hospitalization,
defined
as
a

decline
in
any
ADLs
from

admission
to
discharge,
as
rated

by
the
nurses

− Secondary
outcomes
were
new

institutionalization,
death
during

hospitalization,
and
death
or

new
institutionalization

, 2016
Outcomes:

Reference

Event/Outcome
Time
to

Event

Differences
NNT

Mean/SD
control
Mean/SD
treatment

Cook,
D.,
Thompson,

J.,
Prinsen,
S.,

Dearani,
J.,
&

Deschamps,
C.

(2013).
Functional

Recovery
in
the

Elderly
After
Major

Surgery:
Assessment

of
Mobility
Recovery

Using
Wireless

Technology.
The

Annals
of
Thoracic

Surgery,
1057-‐1061.

− Accelerometer
monitoring
of

mobility
is
effective
to
assess

hospital
surgical
recovery

− Patients
with
the
highest
early

mobility
had
the
shortest
LOS

and
were
less
likely
to
be

discharged
to
skill
nursing

facility
(SNF)
or
required
home

health
care
(HHC)

N/A
− Twenty-‐one
patients
(14%)
were

discharged
with
HHC
or
to
an
SNF,

and
128
(86%)
were
discharged

home
independently

− Hospital
LOS:
5.3
+/-‐
1.4
days

− Significant
differences
in
mobility

were
identifiable
between
those

bound
for
home
independently

and
those
discharged
to
SNF
or

HHC
(p
<
0.001
by
Kruskal-‐Wallis

test);
on
the
first
day,
the
median

steps
measured
in
the
home

independent
group
were
675

(interquartile
[IQ]
range=
862)

versus
108
IQ
range=
481)
steps
in

the
SNF-‐HHC
group;
on
the
second

day,
the
median
steps
measured
in

the
home
independent
group
were

1170
(IQ
range=
1224)
versus
312

(IQ
range=
1015)
steps
in
the
SNF-‐
HHC
group;
on
the
third
day,
the

median
steps
measured
in
the

home
independent
group
were

1431
(IQ
range=
1239)
versus
618

(IQ
range=
1379)
steps
in
the
SNF-‐
HHC
group

N/A

Zisberg,
A.,
Shadmi,

E.,
Sinoff,
G.,
Gur-‐
Yaish,
N.,
Srulovici,

E.,
&
Admi,
H.

(2011).
Low
Mobility

During

− Low
and
moderate
levels
of

mobility
were
shown
to
be

independently
associated
with

greater
functional
decline
in

ADLs
at
discharge
and
at
1-‐
month
follow-‐up
than
was
high

− Hospital
LOS:
7.5
+/-‐
10.4
days

− Of
participants
who
had
low
levels

of
mobility
during
hospitalization,

86%
(n=87)
had
declined
in
ADLs
at

discharge,
71.8%
(n=56)
had

declined
in
ADLs
at
follow-‐up,
and

N/A

, 2016
Hospitalization
and

Functional
Decline
in

Older
Adults.

Journal
of
the

American
Geriatrics

Society,
59(2),
266-‐
273.
Retrieved
July

21,
2014.

mobility
62.3%
(n=48)
had
declined
in
IADLs

at
follow-‐up
[chi-‐square=36.49;

P<.001]

− Of
participants
who
had
moderate

levels
of
mobility
during

hospitalization
65.1%
(n=56)
had

declined
in
ADLs
at
discharge,

65.7%
(n=46)
had
declined
in
ADLs

at
follow-‐up,
and
66.7%
(n=46)
had

declined
in
IADLs
at
follow-‐up

− Of
participants
who
had
high
levels

of
mobility
during
hospitalization

29.2%
(n=99)
had
declined
in
ADLs

at
discharge,
38.5%
(n=109)
had

declined
in
ADLs
at
follow-‐up,
and

52.9%
(n=148)
had
declined
in

IADLs
at
follow
up

Brown,
C.,
Redden,

D.,
Flood,
K.,
&

Allman,
R.
(2009).

The

Underrecognized

Epidemic
of
Low

Mobility
During

Hospitalization
of

Older
Adults.

Journal
of
the

American
Geriatrics

Society,
57(9),
1660-‐
1665.
Retrieved
July

21,
2014.

− On
average,
older
hospitalized

patients
spent
most
of
their

time
lying
in
bed,
despite
an

ability
to
walk
independently

prior
to
admission

N/A
− A
baseline
functional
assessment

indicated
that
35
(77.8%)
patients

were
willing
and
able
to
walk
a

short
distance
independently

− Hospital
LOS:
mean
was
5.1
days

corresponding
to
2,592
one-‐hour

periods
of
data,
median
was
3

days,
with
a
range
of
1
–
29
days

− PT
was
consulted
for
15
(33.3%)

participants,
and
12
(26.7%)

participants
had
documentation
of

walking
with
PT

− No
patient
remained
in
bed
the

entire
measured
hospital
stay,
but

on
average,
83%
+/-‐
12.2%
of
the

measured
hospital
stay
was
spent

lying
in
bed
(16.99
–
22.85
hours

per
day)

− On
average,
12.9
-‐
10.4%
of
the

N/A

, 2016
hospital
stay
was
spent
sitting,
and

3.8
-‐3.5%
was
spent
standing
or

walking,
which
translates
to
an

average
of
3.1
hours
of
sitting
and

55
minutes
of
standing
or
walking

per
day

− The
average
amount
of
time
that

any
one
individual
spent
standing

or
walking
ranged
from
a
low
of

0.2%
to
a
high
of
21%,
with
a

median
of
3%,
or
43
minutes/day
Brown,
C.,
Friedkin,

R.,
&
Inouye,
S.

(2004).
Prevalence

and
Outcomes
of

Low
Mobility
in

Hospitalized
Older

Patients.
Journal
of

the
American

Geriatrics
Society,

52(8),
1263-‐1270.

Retrieved
August
17,

2014.

− Low
mobility
levels
and

complete
bedrest
episodes
are

common
in
hospitalized
older

persons,
occurring
in
16%
and

33%,
respectively,
of
patients
in

this
study

− Low
mobility
is
an
independent

predictor
of
poor
hospital

outcomes
at
discharge,

specifically
decline
in
ADLs,
new

institutionalization,
and
death

N/A
− Hospital
LOS:
median
8
days,
range

3-‐79
days

− Low
and
intermediate
levels
of

mobility
were
common,

accounting
for
80
(16%)
and
157

(32%)
study
patients,
respectively.

− Low
mobility
patients:
functional

decline
occurred
in
62%
(n=32),

new
occurred

in
31%
(n=15),
in-‐hospital
death

occurred
in
24%
(n=19),
and
death

occurred
in
50%
(n=40)

− Intermediate
mobility
patients:

functional
decline
occurred
in
38%

(n=53),
new

occurred
in
19%
(n=26),
in-‐hospital

death
occurred
in
8%
(n=12),
and

death
occurred
in
29%
(n=45)

− High
mobility
patients:
functional

decline
occurred
15%
(n=39),
new

occurred
6%

(n=214,
in-‐hospital
death
occurred

1%
(n=2),
and
death
occurred
8%

(n=22)

, 2016

Clinical
Bottom
Line:

A
review
of
the
literature
found
large
sample
sized
studies
of
moderate
quality
that
consistently
support
an
answer
to
the
presented
research
question.

For

hospitalized
older
adults
aged
65+
years,
low
mobility
does
have
a
negative
effect
on
their
functional
level
at
time
of
discharge.

Low
mobility,
defined
as

decreased
amount
of
steps
taken
throughout
the
day
due
to
laying
in
bed
or
only
transferring
to
a
chair
once
or
twice,
was
associated
with
a
decline
in
ADLs,

being
discharged
to
a
SNF,
going
home
with
HHC,
and
even
death.

Conversely,
high
mobility
was
not
defined
as
mobility
only
with
PT;
rather
it
should
be
the

shared
responsibility
of
the
medical
team
to
overcome
perceived
mobility
barriers
during
hospitalization.

Future
research
should
address
the
most
effective

type
and
amount
of
mobility
needed
to
maintain
function
of
older
persons
in
the
hospital,
as
this
type
of
treatment
is
not
yet
standardized.

SORT
Strength
of
Recommendation:
A;
based
on
four
consistent
level
1
prognostic
prospective
cohort
studies
with
good
follow-‐up

, 2016
References

1.
Gillick
MR,
Serrell
NA,
Gillick
LS.
Adverse
consequences
of
hospitalization
in
the
elderly.
Soc
Sci
Med
1982;
16:
1033–1038.

2.
Kortebein
P,
Symons
TB,
Ferrando
A,
et
al.
Functional
impact
of
10
days
of
bed
rest
in
healthy
older
adults.
J
Gerontol
A
Biol
Sci
Med
Sci
2008;
63A:
1076–
1081.
35.

3.
Troiano
RP,
Berrigan
D,
Dodd
KW,
et
al.
Physical
activity
in
the
United
States
measured
by
accelerometer.
Med
Sci
Sports
Exerc
2008;
40:
181–188.

Critically Appraised Topic 2014

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