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Preserved Physical Fitness Is Associated with Lower 1-Year Mortality in Frail Elderly Patients with a Severe Comorbidity Burden

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Preserved Physical Fitness Is Associated with Lower 1-Year Mortality in Frail Elderly Patients with a Severe Comorbidity Burden Journal name: Clinical Interventions in Aging Article Designation: Original Research Year: 2019 Volume: 14 Clinical Interventions in Aging Dovepress Running head verso: Åhlund et al Running head recto: Åhlund et al open access to scientific and medical research DOI: 198591 Open Access Full Text Article ORIGINAL RESEARCH Preserved physical fitness is associated with lower 1-year mortality in frail elderly patients with a severe comorbidity burden This article was published in the following Dove Medical Press journal: Clinical Interventions in Aging Kristina Åhlund1,2 Introduction: Physical deterioration in connection with a care episode is common. The aim Niklas Ekerstad3,4 of this study was, in frail elderly patients with a severe comorbidity burden, to analyze 1) the Maria Bäck2,5 association between physical fitness measurements and 1-year mortality and 2) the association Björn W Karlson6,7 between preserved physical fitness during the first three months after discharge from emergency Birgitta Öberg2 hospital care and 1-year prognosis. Methods: Frail elderly patients ($75 years) in need of inpatient emergency medical care were 1Department of Physiotherapy, NU included. Aerobic capacity (six-minute walk test, 6MWT) and muscle strength (handgrip strength Hospital Group, Trollhättan, Sweden; 2Department of Medical and Health test, HS) were assessed during the hospital stay and at a three-month follow-up. The results Sciences, Division of Physiotherapy, were analyzed using multivariate Cox regression; 1) 0–12-month analysis and 2) 0–3-month Linköping University, Linköping, For personal use only. Sweden; 3Department of Research and change in physical fitness in relation to 1-year mortality. The analyses were adjusted for age, Development, NU Hospital Group, gender, comorbidity and frailty. 4 Trollhättan, Sweden; Department Results: This study comprised 408 frail elderly hospitalized patients of whom 390 were evalu- of Medical and Health Sciences, Division of Health Care Analysis, able (mean age 85.7 years, Charlson’s index mean 6.8). The three-month mortality was 11.5% Linköping University, Linköping, and the 1-year mortality was 37.9%. After adjustments, the Cox-regression analysis showed that 5 Sweden; Department of Occupational both 6MWT and HS were associated with 1-year mortality, HR 3.31 (95% CI 1.89–5.78, Therapy and Physiotherapy, 6MWT Sahlgrenska University Hospital, p,0.001) and HRHS 2.39 (95% CI 1.33–4.27, p=0.003). The 0–3-month change in the 6MWT Gothenburg, Sweden; 6Department and the HS were associated with 1-year mortality, where patients who deteriorated had a poorer of Molecular and Clinical Medicine, prognosis than those with improved fitness, HR 3.80 (95% CI 1.42–10.06, p 0.007) and Institute of Medicine, Sahlgrenska 6MWT = Academy, University of Gothenburg, HRHS 2.21 (95% CI 1.07–4.58, p=0.032). 7 Gothenburg, Sweden; Department Conclusion: In frail elderly patients with a severe comorbidity burden, physical fitness in of Internal and Acute Medicine, NU Hospital Group, Trollhättan- connection with emergency hospital care was independently associated with 1-year mortality. Clinical Interventions in Aging downloaded from https://www.dovepress.com/ by 130.236.82.206 on 19-Oct-2019 Uddevalla, Sweden Moreover, a change in physical fitness during the first months after hospital care was important for the long-term prognosis. These results emphasize the importance of providing hospital care designed to prevent physical deterioration in frail elderly patients. Keywords: frail elderly, mortality, physical fitness, six-minute walk test, handgrip strength test, in-hospital rehabilitation Introduction Society faces a major challenge in designing healthcare to provide good care for an increasing number of frail elderly patients. When people age, multimorbidity, disability Correspondence: Kristina Åhlund and cognitive impairment become more common, which places substantial demands Department of Physiotherapy, NU on healthcare systems.1,2 Hospital Group, Lärketorpsvägen NÄL, Trollhättan s-46100, Sweden Frailty is a dynamic syndrome with known negative health outcomes, which can Tel +461 0435 4550 improve and worsen over time.3 A frail person is often characterized by a reduced physi- Fax +461 0435 7127 Email [email protected] ological reserve and increased vulnerability, which poses a high risk of a recurrent need submit your manuscript | www.dovepress.com Clinical Interventions in Aging 2019:14 577–586 577 Dovepress © 2019 Åhlund et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you http://dx.doi.org/10.2147/CIA.S198591 hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php). Powered by TCPDF (www.tcpdf.org) 1 / 1 Åhlund et al Dovepress for hospitalization, institutionalization and death.4 In this condi- Materials and methods tion, critical illness requiring hospitalization and prolonged bed This study is a sub-study from the project entitled “Is the rest are associated with physical deterioration and functional Treatment of Frail Elderly Patients Effective in an Elderly impairment persisting for a long time after hospital discharge.5–8 Care Unit” (TREEE), which is a prospective controlled It has been reported that among old, independently walking clinical trial carried out at the NU (NÄL-Uddevalla) Hospital patients, almost 20% require assistance after discharge from Group, in western Sweden. This sub-study focuses on a period of medical inpatient care.9 Suboptimal post-hospital how physical fitness-related variables are associated with recovery leads to a negative spiral in physical function, which mortality and uses a different main outcome (1-year mortal- in turn affects the ability to maintain independence and is ity in comparison to previously reported 3-month mortality). strongly associated with a reduced ability to benefit from medi- All the participants in the study gave their written informed cal interventions and an even poorer prognosis.10–13 consent, by themselves or by proxy. The study was con- There is no consensus definition of frailty, but most ducted in accordance with the Declaration of Helsinki and researchers agree that there are two types of frailty; physi- approved by the regional ethical review board in Gothenburg cal and psychological, where the occurrence of sarcopenia (Entry no: 8883-12, December 12, 2012) and registered at and diminished muscle strength is one important discrimi- the Swedish National Database of Research and Develop- natory characteristic.14,15 One commonly used definition is ment; identifier 113021 http://www.researchweb.org/is/vgr/( The accumulation of deficits model, which adds together a project/113021), November 4, 2012. person’s different diseases and disabilities to produce an index.16 Fried’s definition17 of physical frailty includes the Data collection and procedure following components: unintended weight loss, muscle weak- The original study design, inclusion-and exclusion criteria, ness, self-reported exhaustion, slow gait speed and reduced methods and characteristics of the cohort have already physical activity. It identifies a frail person if three or more been reported.25 of these are fulfilled. Between March 2013 and July 2015, patients aged For personal use only. In frail elderly patients, hospital care is often acute and 75 years or more, frail according to the FRail Elderly Support necessarily has a medical focus.1,18 The association between researcH group (FRESH) screening instrument26,27 and in physical deterioration and hospital care is well known, but, need of inpatient emergency medical care were included despite this, interventions to counteract progressive disability in the study. Patients with severe acute illness suitable for are unusual.5,19 It has been shown that frail patients benefit specialized hospital units, eg, acute myocardial infarction from an interdisciplinary and holistic perspective of care, or stroke, were excluded from the study, as were patients where well-structured rehabilitation is routinely part of the whose informed consent could not be obtained. hospital treatment.20–22 Comprehensive Geriatric Assessment Patients were identified by a general practitioner at the (CGA) is one care model with documented beneficial effects health care center or by the ambulance staff. When they in terms of mortality, disability and cognitive functions.23 found a person aged 75 years or more and in need of medical Clinical Interventions in Aging downloaded from https://www.dovepress.com/ by 130.236.82.206 on 19-Oct-2019 Recently, CGA was found to be superior to conventional inpatient care, they called the geriatric emergency department medical care in preserving aerobic capacity, muscle strength (ED) and the patient was screened for frailty. If the patient and mobility three months after discharge from hospital in was considered frail, he or she became eligible for the study. frail, acutely ill elderly patients.24 The multi-professional The patient could be allocated to a general medical ward, or approach, comprising early
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