Advertisement

Prognostic Interplay of Functional Status and Multimorbidity Among Older Patients Discharged From Hospital

Published:August 09, 2021DOI:https://doi.org/10.1016/j.jamda.2021.07.012

      Abstract

      Objectives

      The purpose of this study was to investigate the prognostic weight of multimorbidity and functional impairment over long-term mortality among older patients discharged from acute care hospitals.

      Design

      A prospective multicenter observational study.

      Setting and Participants

      Our series consisted of 1967 adults aged ≥65 years consecutively admitted to acute care wards in Italy, in the context of the Report-AGE project.

      Methods

      After signing a written informed consent, all patients underwent comprehensive geriatric assessment by Inter-RAI Minimum Data Set acute care. The primary endpoint of the present study was long-term mortality. Patients were grouped into 3 functional clusters and 3 disease clusters using the K-medians cluster analysis. The association of functional clusters, disease clusters, and Charlson score categories with long-term mortality was investigated through Cox regression analysis and the intercluster classification agreement was further estimated. Finally, the additive effect of either disease clusters or Charlson score on predictive ability of functional clusters was assessed by using changes in Harrell’s C-index and categorical Net Reclassification Index (NRI).

      Results

      Functional clusters, disease clusters, and Charlson score were significant predictors of long-term mortality, but the interclassification agreement was poor. Functional clusters predicted mortality with greater accuracy [C-index 0.66, 95% confidence interval (CI) 0.65–0.68] compared with disease clusters (C-index 0.54, 95% CI 0.53–0.56), and Charlson score (C-index 0.58, 95% CI 0.56–0.59). Adding multimorbidity (NRI 0.23, 95% CI 0.14–0.31) or Charlson score (NRI 0.13, 95% CI 0.03–0.20) to functional cluster model slightly improved the accuracy of prediction.

      Conclusions and Implications

      Functional impairment may better predict prognosis compared with multimorbidity, which may be relevant to optimally address individuals’ needs and to design tailored preventive interventions.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of the American Medical Directors Association
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Ritt M.
        • Ritt J.I.
        • Sieber C.C.
        • et al.
        Comparing the predictive accuracy of frailty, comorbidity, and disability for mortality: A 1-year follow-up in patients hospitalized in geriatric wards.
        Clin Interv Aging. 2017; 12: 293-304
        • Torres Moreno B.
        • Núñez González E.
        • Pérez Hernández Dde G.
        • et al.
        [Barthel and Charlson indexes for the prognosis of mortality and institutionalization in hospitalized geriatric patients].
        Rev Esp Geriatr Gerontol. 2009; 44: 209-212
        • Vetrano D.L.
        • Palmer K.
        • Marengoni A.
        • et al.
        Frailty and multimorbidity: A systematic review and meta-analysis.
        J Gerontol A Biol Sci Med Sci. 2019; 74: 659-666
        • Rockwood K.
        • Mitnitski A.
        Frailty in relation to the accumulation of deficits.
        J Gerontol A Biol Sci Med Sci. 2007; 62: 722-727
        • Hoyer E.H.
        • Needham D.M.
        • Atanelov L.
        • et al.
        Association of impaired functional status at hospital discharge and subsequent rehospitalization.
        J Hosp Med. 2014; 9: 277-282
        • Chong E.
        • Ho E.
        • Baldevarona-Llego J.
        • et al.
        Frailty and risk of adverse outcomes in hospitalized older adults: A comparison of different frailty measures.
        J Am Med Dir Assoc. 2017; 18: 638.e7-638.e11
        • Robinson T.N.
        • Wallace J.I.
        • Wu D.S.
        • et al.
        Accumulated frailty characteristics predict postoperative discharge institutionalization in the geriatric patient.
        J Am Coll Surgeons. 2011; 213: 37-44
        • Inouye S.K.
        • Peduzzi P.N.
        • Robison J.T.
        • et al.
        Importance of functional measures in predicting mortality among older hospitalized patients.
        JAMA. 1998; 279: 1187-1193
        • Bossola M.
        • Di Stasio E.
        • Antocicco M.
        • et al.
        Functional impairment is associated with an increased risk of mortality in patients on chronic hemodialysis.
        BMC Nephrol. 2016; 17: 72
      1. Patient-centered care for older adults with multiple chronic conditions: A stepwise approach from the American Geriatrics Society: American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity.
        J Am Geriatr Soc. 2012; 60: 1957-1968
        • Formiga F.
        • Moreno-Gonzalez R.
        • Chivite D.
        • et al.
        High comorbidity, measured by the Charlson Comorbidity Index, associates with higher 1-year mortality risks in elderly patients experiencing a first acute heart failure hospitalization.
        Aging Clin Exp Res. 2018; 30: 927-933
        • Lau T.W.
        • Fang C.
        • Leung F.
        Assessment of postoperative short-term and long-term mortality risk in Chinese geriatric patients for hip fracture using the Charlson comorbidity score.
        Hong Kong Med J. 2016; 22: 16-22
        • Calderón-Larrañaga A.
        • Vetrano D.L.
        • Onder G.
        • et al.
        Assessing and measuring chronic multimorbidity in the older population: A proposal for its operationalization.
        J Gerontol A Biol Sci Med Sci. 2017; 72: 1417-1423
        • Calderón-Larrañaga A.
        • Vetrano D.L.
        • Ferrucci L.
        • et al.
        Multimorbidity and functional impairment-bidirectional interplay, synergistic effects and common pathways.
        J Intern Med. 2019; 285: 255-271
        • Marengoni A.
        • von Strauss E.
        • Rizzuto D.
        • et al.
        The impact of chronic multimorbidity and disability on functional decline and survival in elderly persons. A community-based, longitudinal study.
        J Intern Med. 2009; 265: 288-295
        • Rigler S.K.
        • Studenski S.
        • Wallace D.
        • et al.
        Co-morbidity adjustment for functional outcomes in community-dwelling older adults.
        Clin Rehabil. 2002; 16: 420-428
        • Ryan A.
        • Wallace E.
        • O'Hara P.
        • et al.
        Multimorbidity and functional decline in community-dwelling adults: a systematic review.
        Health Qual Life Outcomes. 2015; 13: 168
        • Marengoni A.
        • Angleman S.
        • Fratiglioni L.
        Prevalence of disability according to multimorbidity and disease clustering: A population-based study.
        J Comorb. 2011; 1: 11-18
        • Martínez-Velilla N.
        • Ibáñez-Beroiz B.
        • Cambra-Contin K.
        • et al.
        Is comprehensive geriatric assessment a better 1-year mortality predictor than comorbidity and prognostic indices in hospitalized older adults?.
        J Am Geriatr Soc. 2013; 61: 1821-1823
        • Landi F.
        • Liperoti R.
        • Russo A.
        • et al.
        Disability, more than multimorbidity, was predictive of mortality among older persons aged 80 years and older.
        J Clin Epidemiol. 2010; 63: 752-759
        • Gray L.C.
        • Bernabei R.
        • Berg K.
        • et al.
        Standardizing assessment of elderly people in acute care: the interRAI Acute Care instrument.
        J Am Geriatr Soc. 2008; 56: 536-541
        • Gagliardi C.
        • Corsonello A.
        • Di Rosa M.
        • et al.
        Preadmission functional decline predicts functional improvement among older patients admitted to acute care hospital.
        J Gerontol A Biol Sci Med Sci. 2018; 73: 1363-1369
        • Travers C.
        • Byrne G.J.
        • Pachana N.A.
        • et al.
        Validation of the interRAI Cognitive Performance Scale against independent clinical diagnosis and the Mini-Mental State Examination in older hospitalized patients.
        J Nutr Health Aging. 2013; 17: 435-439
        • World Health Organization
        PHS-HCF. International classification of diseases, 9th revision. Clinical modifications.
        Public Health Service–Health Care Financing Administration, Washington, DC1980
        • Charlson M.E.
        • Pompei P.
        • Ales K.L.
        • et al.
        A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.
        J Chronic Dis. 1987; 40: 373-383
        • Jain A.K.
        • Dubes R.C.
        Algorithms for clustering data. Prentice-Hall, Inc..
        Division of Simon and Schuster, Upper Saddle River, NJ1988
        • Caliński T.
        • Harabasz J.
        A dendrite method for cluster analysis.
        Communications in Statistics. 1974; 3: 1-27
        • Davies D.L.
        • Bouldin D.W.
        A cluster separation measure.
        IEEE Trans Pattern Anal Mach Intell. 1979; : 1224-1227
        • Ball G.H.
        • Hall D.J.
        ISODATA, a novel method of data analysis and pattern classification.
        Stanford Research Institute, Menlo Park, CA1965
        • Harrell Jr., F.E.
        • Califf R.M.
        • Pryor D.B.
        • et al.
        Evaluating the yield of medical tests.
        JAMA. 1982; 247: 2543-2546
        • Barkhordari M.
        • Padyab M.
        • Hadaegh F.
        • et al.
        Stata modules for calculating novel predictive performance indices for logistic models.
        Int J Endocrinol Metab. 2016; 14: e26707
        • Woo J.
        • Leung J.
        Multi-morbidity, dependency, and frailty singly or in combination have different impact on health outcomes.
        AGE. 2014; 36: 923-931
        • Buja A.
        • Claus M.
        • Perin L.
        • et al.
        Multimorbidity patterns in high-need, high-cost elderly patients.
        PLoS One. 2018; 13: e0208875
        • Vetrano D.L.
        • Rizzuto D.
        • Calderón-Larrañaga A.
        • et al.
        Walking speed drives the prognosis of older adults with cardiovascular and neuropsychiatric multimorbidity.
        Am J Med. 2019; 132: 1207-1215.e1206
        • Landi F.
        • Calvani R.
        • Tosato M.
        • et al.
        Impact of physical function impairment and multimorbidity on mortality among community-living older persons with sarcopaenia: Results from the ilSIRENTE prospective cohort study.
        BMJ Open. 2016; 6: e008281
        • St John P.D.
        • Tyas S.L.
        • Menec V.
        • et al.
        Multimorbidity predicts functional decline in community-dwelling older adults: Prospective cohort study.
        Can Fam Physician. 2019; 65: e56-e63
        • Marengoni A.
        • Akugizibwe R.
        • Vetrano D.L.
        • et al.
        Patterns of multimorbidity and risk of disability in community-dwelling older persons.
        Aging Clin Exp Res. 2021; 33: 457-462
        • Quiñones A.R.
        • Markwardt S.
        • Thielke S.
        • et al.
        Prospective disability in different combinations of somatic and mental multimorbidity.
        J Gerontol A Biol Sci Med Sci. 2018; 73: 204-210
        • Wellens N.I.
        • Verbeke G.
        • Flamaing J.
        • et al.
        Clinical changes in older adults during hospitalization: responsiveness of the interRAI acute care instrument.
        J Am Geriatr Soc. 2013; 61: 799-804
        • Farmer C.
        • Fenu E.
        • O'Flynn N.
        • et al.
        Clinical assessment and management of multimorbidity: summary of NICE guidance.
        BMJ. 2016; 354: i4843
        • Ryan A.
        • Murphy C.
        • Boland F.
        • et al.
        What is the impact of physical activity and physical function on the development of multimorbidity in older adults over time? A population-based cohort study.
        J Gerontol A Biol Sci Med Sci. 2018; 73: 1538-1544
        • Garin N.
        • Olaya B.
        • Moneta M.V.
        • et al.
        Impact of multimorbidity on disability and quality of life in the Spanish older population.
        PLoS One. 2014; 9: e111498
        • Santoni G.
        • Angleman S.
        • Welmer A.-K.
        • et al.
        Age-related variation in health status after age 60.
        PLoS One. 2015; 10: e0120077
        • Caracciolo B.
        • Gatz M.
        • Xu W.
        • et al.
        Relationship of subjective cognitive impairment and cognitive impairment no dementia to chronic disease and multimorbidity in a nation-wide twin study.
        J Alzheimers Dis. 2013; 36: 275-284
        • Cho M.H.
        • Shin D.W.
        • Chang S.A.
        • et al.
        Association between cognitive impairment and poor antihypertensive medication adherence in elderly hypertensive patients without dementia.
        Sci Rep. 2018; 8: 11688
        • Marengoni A.
        • Angleman S.
        • Meinow B.
        • et al.
        Coexisting chronic conditions in the older population: Variation by health indicators.
        Eur J Intern Med. 2016; 31: 29-34