Low Mobility During Hospitalization and Functional Decline in Older Adults

Anna Zisberg, RN, PhD, Efrat Shadmi, RN, PhD, Gary Sinoff, MD, PhD,wz Nurit Gur-Yaish, PhD, Einav Srulovici, RN, MHA, and Hanna Admi, RN, PhD k

OBJECTIVES: To examine the association between mobility levels of older hospitalized adults and functional outcomes. DESIGN: Prospective cohort study. SETTING: A 900-bed teaching hospital in Israel. PARTICIPANTS: Five hundred twenty-ve older (70) acute medical patients hospitalized for a nondisabling condition. MEASUREMENTS: In-hospital mobility was assessed using a previously validated scale. The main outcomes were decline from premorbid baseline functional status at discharge (activities of daily living (ADLs)) and at 1-month follow-up (ADLs and instrumental ADLs (IADLs)). Hospital mobility levels and functional outcomes were assessed according to prehospitalization functional trajectories. Logistic regressions were modeled for each outcome, controlling for functional status, morbidity, and demographic characteristics. RESULTS: Forty-six percent of participants had declined in ADLs at discharge and 49% at follow-up; 57% had declined in IADLs at follow-up. Mobility during hospitalization was twice as high in participants with no preadmission functional decline. Low versus high in-hospital mobility was associated with worse basic functional status at discharge (adjusted odds ratio (AOR) 5 18.03, 95% condence interval (CI) 5 7.6842.28) and at follow-up (AOR 5 4.72, 95% CI 5 1.9811.28) and worse IADLs at follow-up (AOR 5 2.00, 95% CI 5 1.053.78). The association with poorer discharge functional outcomes was present in participants with preadmission functional decline (AOR for low vs high mobility 5 15.26, 95% CI 5 4.8048.42) and in those who were functionally stable (AOR for low vs high mobility 5 10.12, 95% CI 5 2.2844.92).
From the Cheryl Spencer Department of Nursing, zDepartment of Gerontology, and Center for Research and Study of Aging, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel; wDepartment of Geriatrics, Carmel Medical Center, Haifa, Israel; and kNursing Division, Rambam Health Care Campus, Haifa, Israel. Address correspondence to Efrat Shadmi, The Cheryl Spencer Department of Nursing, Faculty of Social Welfare & Health Sciences, University of Haifa, Mount Carmel, Haifa 31905, Israel. E-mail: eshadmi@univ.haifa.ac.il DOI: 10.1111/j.1532-5415.2010.03276.x

CONCLUSION: In-hospital mobility is an important modiable factor related to functional decline in older adults in immediate and short-term (1-month follow-up) functional outcomes. J Am Geriatr Soc 59:266273, 2011.

Key words: functional decline; mobility; hospitalization; older adults; activities of daily living

he effect of hospitalization on functional outcomes has been well established in population-based1,2 and inhospital cohort studies.36 Previous research has indicated that hospitalization adversely affects the functional outcomes of older adults, even in persons with nondisabling conditions and with relatively good baseline function.7 Risk factors for posthospitalization functional decline have been extensively studied,8 yet, only limited research has explored the association between hospitalization care processes and functional outcomes, despite strong theoretical support for the potential adverse contribution of reduced mobility, sensory isolation, hostile environment, decreased nutritional intake, and other factors.9,10 The few studies that have examined in-hospital careprocess factors and functional outcomes have reported mixed results. A recent study examined the performance of care-process quality indicators, including cognitive performance, pain, function, and nutritional status assessments, as well as mobility and creation of discharge plans and found no association between adherence to quality-of-care processes and functional decline in older adults.11 Moreover, the likelihood of functional decline was greater in participants for whom there was a documented effort to improve mobility than for those without such a plan. The authors conclude that such documented efforts to improve mobility might actually indicate a greater level of need, because patients who are independently mobile would not require a documented mobility plan. Another study also addressed mobility, examining the degree and rate of adverse outcomes associated with different mobility levels of

JAGS 59:266273, 2011 r 2011, Copyright the Authors Journal compilation r 2011, The American Geriatrics Society

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hospitalized older adults.12 Controlling for accepted risk factors, it showed that the degree of mobility measured on alternate hospital days was inversely associated with functional decline between admission and discharge. The association between varying levels of mobility during hospitalization and long-term posthospitalization functional outcomes has not been previously studied. Additionally, functional decline before hospitalization has been characterized as an independent risk factor for posthospitalization adverse outcomes.13,14 Nevertheless, previous research has not explored the potentially different association between in-hospital mobility and functional outcomes according to prehospitalization functional trajectories (persons who had declined in function before hospitalization vs those with no preadmission functional change). The present study is part of a larger prospective observational study, Hospitalization Process Effects on Functional Outcomes and Recovery (HoPE-FOR), that was conducted to test the association between hospitalization care processes and functional outcomes in older adults. The objectives of this study were to assess the mobility rates of older hospitalized adults and to determine the degree to which mobility affects functional status at discharge and 1month follow-up. Moreover, it was specically aimed at assessing whether mobility is differently associated with outcomes according to prehospitalization functional trajectories and whether mobility is associated with functional decline even in patients with high functional status before admission.

scores ranged from 0 to 10 correct items,15 higher scores indicating better cognition. A score of 5 or less required the involvement of a surrogate (a family member who serves as the primary caregiver) during the consent process and subsequent interviews.16 After the exclusion of those who refused, those who were not screened at baseline, and those with a SPMSQ score less than 5 without a surrogate caregiver, the 734 patients remaining were eligible for inclusion in the study. Sixteen potential participants died (2.2%). Patients with a length of stay of 2 days or less were excluded for reasons of insufcient time to be affected by the level of mobility during hospitalization.12 An additional 84 (11.5%) patients were not included in the nal sample because they were unable to complete the discharge interview because of deterioration in medical status or inability to collect in-hospital mobility data (patients discharge before the collection of data on in-hospital mobility). The nal study cohort thus included 525 participants, of whom 20% were represented by surrogates. The same surrogates participated in all data collection time points. Surrogates who provided reports were present in the hospital on average 9.3 3.4 daytime hours each day. At the 1-month follow-up, an additional 32 (6.1%) had died, 49 (9.3%) refused to continue participation, and eight (1.5%) were lost to follow-up, leaving a nal study followup sample of 436 participants.

METHODS Setting and Participants The population assessed for potential recruitment to the study consisted of 2,534 older patients (70) admitted to one of ve general medical inpatient units of a 900-bed tertiary care teaching hospital in Israel from February to November 2009. Patients who, on admission, had a stroke or were in a coma, mechanically ventilated, or completely dependent in basic functions were not eligible for participation in the study. In addition, patients who were admitted electively or transferred from other units in the hospital were excluded (Figure 1). The hospital and Ministry of Health review boards approved the study. Trained research assistants approached 80.2% of the 1,444 potential participants, within 48 hours of their admission. Inability to reach patients after ve attempts within 48 hours was mainly a consequence of their medical condition (e.g., patients were undergoing intensive medical treatment or were in such a deteriorated physical state as to preclude participation in the study). Those who could not be reached within 48 hours of admission were not eligible to participate in the study because it was not possible to evaluate their functional status on admission or to monitor their daily mobility prospectively throughout the period of hospitalization. Of the eligible participants, 414 (24.1%) refused participation, primarily because of being too tired and weak and privacy concerns. Finally, ability to sign an informed consent form and participate in the interviews was assessed using the Short Portable Mental Status Questionnaire (SPMSQ). Total

Assessment Two bilingual (Hebrew-Russian and Hebrew-Arabic) research assistants conducted all interviews to cover the main languages spoken in Israel. The interviewers underwent intensive training and were blinded to the study hypotheses. The interrater reliability of all study measures assessed was high (kappa 5 0.96). The baseline interview included items on demographic data, living conditions, and self-assessment of functional status using the modied Barthel Index (BI) for activities of daily living (ADLs)17 and Lawton and Brodys scale for instrumental activities of daily living (IADLs).18 ADLs and IADLs were assessed to determine premorbid functional status (baseline at 2 weeks before admission)19 and functional status at the time of admission. The preadmission functional trajectory was measured as change between premorbid ADLs and admission according to BI scores and was dichotomized as preadmission functional decline versus functional stability (negative change vs no or positive change in BI score). The baseline interview also included assessment of level of mobility during the month before admission, using the Yale Physical Activity Survey (YPAS).20 Participants reported how much time they spent on a comprehensive list of activities, as well as the frequency and duration of physical activity in ve categories (vigorous activity, leisurely walking, moving, standing, and sitting) during a typical week. An index score for each category is computed as a product of frequency, duration, and a weighting factor related to the intensity of physical activity for that category, reecting the total physical activity performed by an individual during a typical week. Total score ranges from 0 to 136 points. Hospital mobility levels were assessed through daily interviews with a participant or surrogate using a modication

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2,534 patients 70 and older admitted to a general medical inpatient unit at the study center February 2009 November 2009

1,090 Excluded: Admitted with cerebrovascular disease, coma, or mechanical ventilation (n=269, 10.62%) Elective hospitalization (n=108, 4.3%) Spoken language of patient or caregiver not Hebrew, Arabic, or Russian (n=54, 2.13%) Unable to communicate and no surrogate available (n=318, 12.55%) Transferred from intensive care unit or another unit (n=69, 2.7%) Discharged before approached by research assistant (n=185, 7.3 %) Completely dependent at baseline (n= 87, 3.4%)

1,444 Eligible patients (57%)

710 Excluded: Screening not performed in first 48 hours (n=285, 16.61%) Refusal (n=414, 24.13%) 734 Eligible patients screened Cognitive status on the Short Portable Mental Status Questionnaire <5 and no surrogate available (n=11, 1.47 %)

206 Excluded Died in hospital (n=16, 2.2 %) Length of stay 2 days or less (n= 106, 14.44%) Discontinued participation (n=84, 11.46%)

525 patients at discharge Final sample for discharge outcome 89 Excluded: Unable to reach after 20 phone calls (n=8, 1.5%) Discontinued participation (n=49, 9.3%) Died (n=32, 6.1%)

436 patients for final analysis Final sample for 1-month follow-up outcomes

Figure 1. Participant recruitment to and exclusion from the study.

of a mobility index developed previously.12 Participants were asked about the frequency of all mobility efforts of any type (physical therapy, initiated by others, or self-initiated) in the previous 24-hour period. Interviews were conducted each day after the rst 48 hours and were averaged for all available reports (up to three reports). In addition to frequency of ambulation and transfer, the original scale was modied to include an evaluation of distance (classied as inside or outside the participants hospital room). Scores ranged from 0 to 14, with higher scores indicating greater mobility. 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 for admission data needed to calculate the Acute Physiology, Age, and Chronic Health Evaluation (APACHE II) score21 and the Charlson Comorbidity Index (CCI)22 and to determine discharge destination or death. Transfer to intensive care was indicated if the participant was transferred to an intensive care

unit (ICU), a coronary care unit (CCU), or an intermediate ICU (for complex patient care inside the Internal Medicine unit) and was dichotomized as intensive care versus no intensive care. The majority of discharge interviews (80%) were conducted in person with participants or surrogates during the last day of hospitalization on site. Participants current ability to perform ADLs was assessed using the BI. If participants or surrogates were not met with at time of discharge, telephone interviews were conducted within 3 days. Participants and surrogates were asked to provide their evaluation of functional status as it was on the day of discharge. One-month follow-up interviews assessing ADL and IADL abilities were conducted in a 20-minute (on average) telephone interview with participants or surrogates.

Outcomes The 10-item BI to measure functional status in 10 areas of ADLs was completed by an interviewer at each point of assessment. Total scores range from 0 to 100, with higher

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scores indicating better functional status. A decline in functional status was dened as worsening of BI score, comparing the premorbid with the discharge ADL assessments.19,23 Similarly, secondary outcomes were dened as worsening in functions from the premorbid to the 1-month follow-up ADL or IADL assessments. All outcomes were dichotomized as decline versus stability or recovery to premorbid functional status.

Data Analysis The characteristics of the study participants were described for the entire sample and according to each preadmission functional trajectory (with and without preadmission functional decline). Differences in the characteristics of persons with and without preadmission functional decline were tested, using t-tests for continuous variables and chi-square tests and for categorical variables. The relationship between mobility level and each of the study outcomes was examined using bivariate analysis, yielding crude odds ratios (ORs) and associated 95% condence intervals (CIs). Multivariate logistic regressions were modeled to assess the effect of mobility levels during hospitalization on each functional outcome, controlling for all seven risk factors determined as important predictors of posthospitalization functional decline:8 premorbid functional status (BI and IADLs), age, sex, comorbidity (CCI), severity of illness (APACHE II), length of stay, and cognitive status (SPMSQ). Additional covariates were a dummy indicator of whether the participant or a surrogate completed the questionnaire,16 transfer to any ICU, and level of mobility (YPAS) during the premorbid period. Logistic regressions were also modeled separately for each preadmission trajectory. To account for the potential different effect of small and large declines in premorbid functional status, sensitivity analyses were conducted for the subgroup of participants with preadmission functional decline, controlling for degree of change in functional status before hospitalization. To specically assess the degree to which mobility affects the outcomes of a highly functional cohort, additional logistic regressions were modeled for the subgroup of participants who had high BI scores on admission (90100), controlling for the abovementioned covariates. Analyses were performed using Stata version 10 (Stata Corp., College Station, TX). RESULTS The baseline characteristics of all study participants according to each preadmission functional trajectory are presented in Table 1. Overall, mean age was 78.3 6.0. The majority of participants were community dwellers and were married. Sixty-six percent were Hebrew speakers, 27% were Russian speakers, and 7% were Arab speakers. Participants who completed the study process from the time of admission through hospitalization and assessment at discharge (N 5 525) were similar to those who withdrew (n 5 84) with regard to sex (female: 49.5% vs 52.8%, P 5 .65), preadmission functional status (BI score: 87.0 vs 84.54, P 5 .41), comorbidity (2.3 vs 2.7, P 5 .13), severity of illness (APACHE II: 10.42 vs 10.31, P 5 .84), cognitive status (SPMSQ: 7.98 vs 7.43, P 5 .10), and age (78.85 vs 79.43, P 5 .40). No signicant differences were found be-

tween participants who completed the 1-month follow-up (n 5 436) and those who had withdrawn by then (n 5 57) with regard to sex (female: 51.6% vs 44.9%, P 5 .45), preadmission functional status (BI score: 87.3 vs 88.5 P 5 .68), comorbidity (2.3 vs 2.6, P 5 .36), severity of illness (APACHE II: 10.4 vs 10.0, P 5 .46), cognitive status (SPMSQ: 8.0 vs 8.0, P 5 .96), and age (78.7 vs. 80.3, P 5 .08). Average premorbid and admission BI scores were 87.0 20.8 and 75.4 30.5, respectively, indicating minor to moderate dependency.24 Average premorbid IADL score was 10.4 5.3. As in other studies of frail older adults,25 study participants scored an average of 20.6 points on the premorbid YPAS measure, indicating low mobility. Mean length of stay was 7.5 days and median was 5 days. Participants who declined in physical function before admission were typically 2 years older (Po.001); more likely to be female (60% vs 40%, Po.001), less educated (Po.002), and signicantly more limited in cognitive and physical function (Po.001); and scored 10 points lower on the YPAS index for activity (Po.001). Overall, 46% of the participants had declined in ADLs at discharge from their premorbid basic function, 49% had declined in ADLs at follow-up, and 57% had declined in IADLs at follow-up. Those who reported no premorbid functional decline were approximately 2.5 times as likely to recover to their premorbid functional status as their counterparts (Po.001). Most participants (65%) were classied as highly mobile (walked on average at least once a day outside their room) during their entire hospitalization, 16% were moderately mobile (walked only inside their room), and 19% percent were restricted to bed or only transferred from bed to chair. Participants who experienced premorbid functional decline were less likely to be highly mobile during their hospitalization than were those who did not (45% vs 84%). Of participants who had low levels of mobility during hospitalization, 86% had declined in ADLs at discharge, 73% had declined in ADLs at follow-up, and 63% had declined in IADLs at follow-up (chi-square 5 36.49; Po.001). There was a clear gradient in functional decline across the various mobility levels (Figure 2). Table 2 presents the crude and adjusted ORs and CIs according to mobility level for all outcomes. The odds of basic functional decline at the time of discharge, as well as at the 1-month follow-up, were signicantly higher for low and moderately mobile participants than for highly mobile participants. These results remained stable after adjusting for premorbid functional status, age, sex, comorbidity, cognitive status, YPAS score, APACHE II score, length of hospital stay, surrogate response, and transfer to ICU. The odds of IADL decline were also greater for low and moderately mobile participants than for highly mobile participants. There was a clear gradient in the odds of functional decline according to mobility level for all outcomes. To test the different associations between mobility levels and study outcomes at each preadmission functional trajectory, crude and adjusted ORs and CIs were calculated separately for each trajectory (Table 3). The adjusted OR for functional decline at discharge in participants who had declined in functional status before admission was 15.3 (95% CI 5 4.848.42) for those with low versus high

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Table 1. Characteristics of Study Population in Total Sample and According to Each Prehospitalization Functional Trajectory
Total N 5 525 Decline in Function Before Hospitalization n 5 263 Stable Before Hospitalization n 5 262 P-Value for Group Comparisons

Characteristic

Age, mean SD Female, n (%) Married or living with partner, n (%) Education, mean SD Admitted from a nursing home or living with a paid caregiver, n (%) Surrogate respondent, n (%) Short Portable Mental Status Questionnaire, mean SD (range 010) Charlson index, mean SD (range 033) Acute Physiology, Age, and Chronic Health Evaluation score, mean SD Length of stay, days, mean SD) Transferred to intensive care unit, n (%) Yale Physical Activity Survey Index, mean SD range (0136) Total ADL score at admission, mean SD (range 0100) Total premorbid ADL score, mean SD (range 0100) Total premorbid instrumental ADL score, mean SD (range 016)
Higher score indicates higher cognitive status. ADL 5 activity of daily living; SD 5 standard deviation.

78.9 5.9 260 (49.5) 289 (55.2) 10.2 5.4 45 (8.7) 105 (20) 8.0 2.3 2.3 2.1 10.4 3.5 7.5 10.4 37 (7) 20.6 17.8 75.4 30.5 87.0 20.7 10.4 5.3

79.9 6.0 157 (59.7) 124 (47.2) 9.5 5.7 32 (12.2) 83 (31.6) 7.2 2.7 2.4 2.0 11.0 3.8 8.4 11.4 22 (8.4) 16.1 15.9 57.9 31.6 81.5 22.9 8.2 5.1

77.8 5.7 103 (39.3) 165 (62.9) 11 4.9 15 (5.30) 22 (8.4) 8.7 1.5 2.3 2.1 9.9 3.1 6.5 9.2 15 (5.2) 25.2 18.4 93.3 15.6 92.5 16.6 12.6 4.5

o.001 o.001 o.001 .002 o.001 o.001 o.001 .52 o.001 .04 .24 o.001 o.001 o.001 o.001

in-hospital mobility. Moderately mobile participants with preadmission functional decline had an adjusted OR of 3.28 (95% CI 5 1.57.14) versus their highly mobile counterparts. These results remained signicant in sensitivity
100%

analyses, controlling also for degree of preadmission functional change. For the stable group, the OR was also high for participants with low versus high hospitalization mobility levels (OR 5 10.12, 95% CI 5 2.2844.92), as well as

90% 80% Percentage with change from baseline 70% 60% 50% 40% 30% 20% 10% 0%

87.0% (n=87) 71.8% (n=56) 65.1% (n=56) 65.7% (n=46) 62.3% (n=48)

66.7% (n=46)

52.9% (n=148) 38.5% (n=109) 29.2% (n=99)

Declined in ADL at discharge (n=525, p<0.001)

Declined in ADL at 1-month follow-up (n=431, p<0.001)

Declined in IADL at 1-month follow-up (n=426, p=0.06)

Figure 2. Decline in functional status according to mobility level. For each outcome, the light bars indicates low mobility (total bed rest or transferring from bed to chair up to twice a day), the checked bars indicate moderate mobility (ambulation inside the room only), and the dark bars indicate high mobility (ambulation at least once a day outside the room in addition to mobility inside the room). ADLs 5 activities of daily living; IADLs 5 instrumental activities of daily living.

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Table 2. Likelihood of All Outcomes According to In-Hospital Mobility Level

Odds Ratio (95% Condence Interval) Decline in ADL Function from Premorbid to 1-Month Follow-Up (N 5 431) Crude Adjusted Decline in Instrumental ADL Function from Premorbid to 1-Month Follow-Up (N 5 426) Crude Adjusted

Decline in ADL Function from Premorbid to Discharge (N 5 525) In-Hospital Mobility Level (Reference: High Mobility) Crude Adjusted

Moderatew Lowz

4.52 (2.747.47) 16.22 (8.6530.40)

4.09 (2.277.37) 18.03 (7.6842.28)

3.06 (1.775.30) 4.06 (2.357.03)

2.11 (1.074.15) 4.72 (1.9811.28)

1.78 (1.033.01) 1.48 (0.882.48)

1.97 (0.934.15) 2.00 (1.053.78)

Ambulation at least once a day outside the room in addition to mobility inside the room. Ambulation inside the room only. z Total bed rest or transferring from bed to chair up to twice a day. Adjusted for age, sex, cognitive status, physical activity level at baseline, basic and instrumental functional status at baseline, Charlson comorbidity score, acute physiology score, length of hospital stay, transfer to intensive care unit, and whether interviews were conducted with a surrogate. ADL 5 activity of daily living.

for participants with moderate versus high mobility levels (OR 5 3.74, 95% CI 5 1.3210.6). The odds of ADL decline at discharge for participants with no functional limitations on admission was 6.2 for low versus high mobility levels (95% CI 5 1.0037.7). Participants who had declined in functional status before admission and had low hospital mobility had 3.99 greater (adjusted) odds (95% CI 5 1.3911.45) than patients with high mobility levels of declining in ADLs at 1-month follow-up. Similarly, these patients had 2.73 greater (adjusted) odds (95% CI 5 1.16 6.43) of declining in IADLs at 1-monh follow-up. A trend in the same direction was observed, for all other outcomes for low and moderate mobility levels.

DISCUSSION This study supports previous ndings12 on the deleterious effects of low mobility during hospitalization. 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 mobility. Moreover, the gradient in functional decline according to mobility level indicates a dose effect of in-hospital mobilization on functional outcomes. These relationships remained signicant after controlling for basic function, morbidity, and demographic variables. As expected, the effect of mobility was stronger for immediate than followup functional outcomes. It was hypothesized that hospital mobility levels would affect change in instrumental, and not only basic, functional status because of the interrelationships between ADLs and IADLs.26,27 The results indicate that mobility exerts some effect on IADLs, although less than on ADLs and with only marginal statistical signicance for moderate versus high mobility (P 5 .06). This lower effect of mobility would be expected, given that IADLs are a more complex indicator than ADLs and are based on higher functions, such as cognition, in addition to some physical capabilities.27,28 An important potential explanation for the effect of mobility on functional outcomes is that low levels of mobility reect the severity of illness and high levels of intensive care, which may hinder patients activity during hospitalization. To account for this explanation, several

steps were taken. First, the selection of study participants was restricted to patients who were directly admitted to internal medical units and excluded those who were transferred from higher levels of care (e.g., ICU). Second, people who were suffering from a debilitating illness (e.g., cerebrovascular accident or femoral hip fracture) were excluded from the study. All patients who died during hospitalization and those who were completely dependent in ADLs at admission were also excluded from the nal analyses. Finally, the analyses were adjusted for severity of illness on admission, length of stay, and transition to intensive care during hospitalization, thus controlling for severity of illness and intensity of care. Low mobilization during hospital stays is a common phenomenon, with low hospital mobility documented as early as 2 decades ago.29 Previous research indicates that between 73% and 83% of the measured hospital stay of older adults is spent lying in bed.30,31 The current study adds to previous ndings reported in the literature in several aspects. Functional decline has been shown to differ between patients according to their preadmission functional trajectory, with worse outcomes in those who had demonstrated decline in the prehospital period.16,19 As such, preadmission functional decline is considered to be an important risk factor for posthospitalization functional outcomes and mortality.13 The results of the current study show that low mobility was signicantly associated with decline in short- and long-term outcomes for participants with preadmission functional decline as well as for participants who were functionally stable before admission. The strong positive relationship between mobility and outcomes in older adults with and without preadmission functional decline with high, moderate, and low mobility levels indicates that it is an important hospitalization factor that may affect frail and more-resilient older adults. Moreover, approximately 44% of the study participants had a high BI score on admission yet were signicantly affected by low mobility during hospitalization. These results indicate that even persons who are not considered high risk using common screening tools32,33 may be at risk for posthospitalization functional decline related to their low in-hospital mobility levels. Thus, promoting mobility may be important even for groups not generally considered to be at high risk.

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Only one previous study measured mobility and examined the relationship between in-hospital mobility and change in functional outcomes between admission and discharge.12 The current study indicates the importance of mobility not only for recovery to functional status at the time of admission, but also for return to baseline functional status before exacerbation of the persons condition (premorbid functional status). An additional contribution of this study is that it shows the effect of mobility during short hospital stays (median length of stay of 5 days) in a sample of older adults who were less frail than in similar research.12 This study has several limitations. First, the study sample is of older adults hospitalized at only one medical center in Israel. Because mobility can vary according to service and institution types, the results from one study may not be generalizable to other settings, although the mobility levels found in this study, as well as their effects on functional outcomes, are similar to those reported in a study conducted in the United States12 and that the average length of stay of older adults is similar to that reported in recent U.S. studies (considering exclusion of stays of 48 hours in the current sample).4,11 Generalizability may also be limited because of study attrition. Participants who completed all phases of data collection may be different from those who were lost to follow-up. The main reasons for withdrawal from the study were being too sick or unavailable because of intensive tests or procedures. The design of this study precludes causality from being determined. Whether, in a controlled situation, moving around more will have a benecial effect on functional status was not tested. One study found that, in a sample of younger older adults (mean age 67 5), 10 days of bed rest had no effect on physical performance, although older individuals are more sensitive to the effects of bed rest inactivity than younger cohorts.34 Because the current sample included older adults, with several risk factors, low mobilization might have demonstrated a stronger relationship with outcomes than that reported in a healthy cohort. Additionally, many other factors, such as low motivation or illness severity aspects not captured by the APACHE or Charlson scores, may affect low mobilization as well as functional outcomes. These aspects require further research manipulating the level of mobility and tightly controlling for intervening factors. The measure of mobility used in this study has several limitations. First, although the original scale is based on nurses reports, the assessment of actual mobility here was based on participant or surrogate reports. The criterion standard for mobility measurement is direct behavioral observation.12,35 This type of assessment is beyond the scope of this study. Although participants reports may be subject to recall bias, nurses reports may also be incomplete because they do not directly observe participant mobility. Therefore, future research is required to test the associations with observed rather than reported mobility. Additionally, for 20% of the sample, surrogates provided reports. Incomplete data from surrogates (because of partial presence) might bias the ndings, although the data show that surrogates were present almost all of the day and thus were in a position to provide consistent reports.

In-Hospital Mobility Level (Reference: High Mobility)

Moderate Lowz

Ambulation at least once a day outside the room in addition to mobility inside the room. Ambulation inside the room only. z Total bed rest or transferring from bed to chair up to twice a day. Adjusted for age, sex, cognitive status, physical activity level at baseline, basic and instrumental functional status at baseline, Charlson comorbidity score, acute physiology score, length of hospital stay, transfer to intensive care unit, and whether interviews were conducted with a surrogate. ADL 5 activity of daily living.
w

Table 3. Likelihood of All Outcomes According to Each Preadmission Trajectory

2.06 (1.345.06) 3.28 (1.507.14) 3.73 (1.649.41) 3.74 (1.3210.60) 2.09 (1.014.32) 2.19 (0.935.20) 2.23 (0.865.81) 1.62 (0.475.55) 1.80 (0.883.71) 2.44 (0.966.26) 1.33 (0.513.46) 1.33 (0.434.07) 12.46 (5.0430.80) 15.26 (4.8048.42) 7.29 (2.6620.00) 10.12 (2.2844.92) 2.29 (1.144.53) 3.99 (1.3911.45) 4.14 (1.4311.96) 10.18 (1.7260.30) 1.37 (0.712.63) 2.73 (1.166.43) 1.24 (0.443.48) 2.28 (0.539.93)

Decline in Instrumental ADL Function from Premorbid to 1-Month Follow-Up (N 5 426)

Stable (n 5 214) Decline (n 5 212) Stable (n 5 216) Decline (n 5 215) Stable (n 5 262) Decline (n 5 263)

Odds Ratio (95% Condence Interval)

Decline in ADL Function from Premorbid to 1-Month Follow-Up (N 5 431)

Decline in ADL Function from Premorbid to Discharge (N 5 525)

Crude

Adjusted

Crude

Adjusted

Crude

Adjusted

Crude

Adjusted

Crude

Adjusted

Crude

Adjusted

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FEBRUARY 2011VOL. 59, NO. 2

IN-HOSPITAL MOBILITY LEVELS AND FUNCTIONAL DECLINE

273

In conclusion, the results of this study show that inhospital mobility level is associated with functional decline of older adults at discharge and, even more so, at follow-up. In-hospital mobility, unlike personal and disease-related risk factors, is a potentially modiable care aspect that has important implications for in-hospital care regimes. Level of mobility is similarly related to functional outcomes of patients who experience functional decline before their hospitalization and those who are functionally stable, indicating the value of developing and evaluating a policy for the early and effective mobilization of all older hospitalized patients in general medical units.

ACKNOWLEDGMENTS The authors would like to acknowledge the valuable contribution of Veronika Didora and Yael Ailon for their assistance in data collection. Conict of Interest: The editor in chief has reviewed the conict of interest checklist provided by the authors and has determined that the authors have no nancial or any other kind of personal conicts with this paper. Einav Srulovici was employed as a research fellow on the Israeli Science Foundation grant funding this study (565/08). Author Contributions: Anna Zisberg and Efrat Shadmi conceptualized the study, obtained funding, analyzed and interpreted the data, and prepared the manuscript. Gary Sinoff and Nurit Gur-Yaish conceptualized the study, obtained funding, and provided critical revisions to the manuscript. Hanna Admi was involved in acquisition of data and review of the nal draft of the manuscript. Einav Srulovici was responsible for acquisition of subjects and data, analyzed and interpreted the data, and was involved in preparation of this manuscript. Sponsors Role: The funding agencies had no role in the design, methods, analysis, or preparation of the manuscript. REFERENCES
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