Deconditioned, disabled, or debilitated? Formalizing management of functional mobility impairments in the medical inpatient setting

Martinez M, Falvey JR, Cifu AS. Deconditioned, disabled, or debilitated? Formalizing management of functional mobility impairments in the medical inpatient setting. Journal of Hospital Medicine. 2022;17(10):843-846. doi:10.1002/jhm.12910

Link to Original Article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9796863/

Key Points

1. Hospital-associated disability (HAD) is a common condition where older adults become unable to complete activities of daily living after discharge from the hospital. Over a quarter of those with HAD will experience prolonged disability.

2. Older adults with low mobility during hospitalization are more likely to be institutionalized at discharge and more likely to die.

3. There is a lack of standardized guidance on how to recognize, diagnose, and treat functional mobility impairments in the medical acute care setting.

4. The development of a clinical practice guideline (CPG) for the management of HAD and physical deconditioning in hospitalized patients is proposed to improve management of these conditions.

5. Terminology, risk assessment and diagnostics, and treatment strategies need to be clarified and standardized.

6. Early mobilization and rehabilitation have been shown to be effective in reducing functional decline, length of stay, institutionalization, disability, and mortality in hospitalized patients. Treatment should be tailored to the patient and consider the severity of illness, and future research should focus on predictive scores and optimal dosing of rehabilitation interventions.

Introduction

This research paper focuses on hospital-associated disability (HAD) and other functional mobility impairments in older adults. The paper highlights that a significant proportion of older adults admitted to hospitals experience HAD and become unable to complete activities of daily living. HAD can lead to prolonged disability, institutionalization, and even death. However, hospitalists lack knowledge on managing HAD and other related impairments. The paper suggests that managing these conditions should be approached in a similar way to managing other diseases in the hospital setting. To effectively manage inpatient functional mobility impairments, the paper recommends three key areas to focus on: clarification of terminology, risk assessment and diagnostics, and treatment strategies. By addressing these aspects, hospitalists can enhance their understanding and management of HAD and other functional mobility impairments in older adults.

Is It Time For A Clinical Guideline?

This section of the research paper discusses the need for a clinical practice guideline (CPG) to address the management of hospital-associated disability (HAD) and physical deconditioning in older adults. It highlights a case study of a patient who experienced functional mobility impairments during their hospitalization, leading to a nonhome discharge. The paper emphasizes that these impairments are often overlooked in medical settings, and there is a lack of standardized guidance for recognizing, diagnosing, and treating them. The authors propose the development of a evidence-based CPG to prioritize, diagnose, and intervene upon these impairments during hospitalization.

Terminology

Which term should be used to describe functional mobility impairments in the hospital?

They suggest using the terminology of HAD for acute activities of daily living (ADL) impairments and physical deconditioning for new impairments in physical performance. The paper highlights the importance of consistent terminology to recognize these conditions as diseases requiring attention during hospitalization. The authors state that an explicit link between recommendations and supporting evidence is crucial in the development of the CPG. They used the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument to assess the need for a medical inpatient mobility CPG. Overall, the paper calls for the creation of a CPG to address functional mobility impairments in older adults, emphasizing the importance of evidence-based and unbiased development.

Population

Who should be assessed?

The paper discusses the population that should be assessed for hospital-associated disability (HAD) and physical deconditioning. Currently, there are no validated scores that combine risk factors to create an overall risk score for these conditions in patients hospitalized for acute medical conditions. However, numerous studies have identified age, cognitive and mood disorders, level of function prior to admission, and the need for assistive devices with ambulation as significant risk factors. As a result, experts recommend conducting mobility assessment for all patients at the time of admission, as bedrest is detrimental for almost everyone. This recommendation is currently based on expert opinion, but future research focusing on prediction scores and validated screening tools could provide stronger evidence supporting this practice. It is likely that screening would continue to be recommended for all hospitalized patients, even with the use of such tools. Overall, assessing the population at risk for HAD and physical deconditioning is crucial in order to effectively manage these conditions in older adults.

Diagnosis

How do we diagnose HAD and physical deconditioning?

The American Geriatrics Society has identified 14 validated tools for evaluating functional mobility and physical performance in older adults. Two assessments, the Activity Measure Post-Acute Care (AM-PAC) score and the Johns Hopkins Highest Level of Mobility (JH-HLM) score, have demonstrated reliability and construct validity for assessments done by nurses and therapists in the acute care setting. These tools can be used for the diagnosis of Hospital-Associated Disability (HAD) and physical deconditioning. Future research should focus on determining the predictive precision of these diagnostic cutpoints to guide treatment intensity.

Treatment

How do we treat functional mobility impairments in the medical acute care setting?

To effectively manage functional mobility impairments in the medical acute care setting, early mobilization is crucial. This can be done by physical and occupational therapists, nursing staff, or other trained individuals. Studies have shown that early mobilization and rehabilitation significantly reduce length-of-stay, functional decline, institutionalization, disability, and mortality in hospitalized patients. Treatment should be tailored to the individual patient, considering the severity of illness. An optimal clinical practice guideline (CPG) should not only recommend mobilization but also specify the dosage, frequency, and mode of delivery for rehabilitation.

In conclusion, healthcare providers should utilize validated tools such as the AM-PAC and JH-HLM scores to diagnose HAD and physical deconditioning in older adults. Early mobilization, guided by an effective CPG, is crucial for managing functional mobility impairments in the hospital setting. Tailoring treatment to the patient's needs and considering the intensity and duration of rehabilitation is essential for optimal outcomes.

If Not Now, Then When?

The lack of systematic management of functional mobility impairments in older adults by hospitalists is concerning, given the existing literature on the diagnosis, treatment, and consequences of these impairments. Currently, physical or occupational therapists are often consulted to triage and treat mobility issues, but they are not always necessary and can be a limited resource. Allocating skilled therapy to vulnerable patients is crucial for treating and preventing hospital-associated disability (HAD) and physical deconditioning, but the current standards of practice do not facilitate this targeting. While the current evidence may only support level 2B recommendations, the development of guidelines for managing functional mobility impairments could greatly improve the care provided by hospitalists. Such guidelines would also help focus future research efforts and move towards stronger level 1A recommendations. It is important for clinicians to recognize the distinct "mobility maladies" and "ability ailments" that older adults experience during their hospitalization, and to manage these conditions like other medical conditions. By formalizing the understanding of these impairments and their impact on patients' lives, clinicians can take essential steps towards promoting home and functional independence for their patients.

Opportunities for Future Research

1. Conduct a formal literature review to investigate the prevalence and risk factors for hospital-associated disability (HAD) and physical deconditioning in patients hospitalized for acute medical illness.

2. Develop and validate predictive scores or tools that combine risk factors to accurately assess the likelihood of developing HAD or physical deconditioning.

3. Investigate the use of validated functional mobility assessments, such as the Activity Measure Post-Acute Care (AM-PAC) score and the Johns Hopkins Highest Level of Mobility (JH-HLM) score, in diagnosing HAD and physical deconditioning in the acute care setting.

4. Conduct research on the optimal dose, frequency, and mode of delivering mobilization interventions to treat and prevent HAD and physical deconditioning in hospitalized patients.

5. Develop a standardized clinical practice guideline (CPG) for the management of HAD and physical deconditioning in patients hospitalized for acute medical illness, based on evidence-based recommendations.

6. Evaluate the impact of implementing the CPG on functional outcomes, length of stay, institutionalization rates, disability, and mortality in hospitalized patients with functional mobility impairments.