Aging Clin Exp Res (2013) 25:633–636 DOI 10.1007/s40520-013-0162-2
ORIGINAL ARTICLE
Predictive effects of muscle strength after hospitalization in old patients Gianluca Isaia • Francesca Greppi • Alessandra Pastorino • Erika Maria Bersano Sokol Rrodhe • Nicoletta Aimonino Ricauda • Mario Bo • Katia Molinar Roet • Mauro Zanocchi
•
Received: 6 November 2012 / Accepted: 17 June 2013 / Published online: 23 October 2013 Ó Springer International Publishing Switzerland 2013
Abstract Background and aims Frailty is a common situation that often influences clinical outcomes, disability or institutionalization. The present study aims to evaluate the weight of hand grip strength (HGS) reduction in terms of death or re-hospitalizations, at 3-month and 1-year follow-up. Methods Observational study performed on hospitalized patients aged 65 years or more. The HGS was measured twice: at hospital admission and discharge. The statistical analysis was performed using SPSS, version 18 for Windows. The v2 test was used to evaluate the relationship between HGS and different variables. Three-month and 1-year survival and hospital re-admissions have been analyzed using Kaplan–Meier’s curves. The analyses have been adjusted for age and gender. Results A total of 201 hospitalized patients have been recruited. Of them, 76 were males. The mean age was 81.79 ± 7.409 years. Of all the patients enrolled, 66.2 and 45.3 % did not show any impairment performing activities of daily living and instrumental activities of daily living, respectively. Moreover, patients were not cognitively impaired [SPMSQ (short portable mental status questionnaire ) m ± SD = 1.47 ± 0.794]. At 3-month follow-up patients with strength reduction had a relative risk of death more than seven times higher than the others (p = 0.047).
G. Isaia F. Greppi (&) A. Pastorino S. Rrodhe Geriatric Division, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Regione Gonzole 10, 10043 Orbassano (Turin), Italy e-mail: [email protected] E. M. Bersano N. Aimonino Ricauda M. Bo K. Molinar Roet M. Zanocchi Geriatric Section, Department of Medical and Surgical Disciplines, S. Giovanni Battista Hospital, University of Torino, Turin, Italy
Same results were observed at 1-year follow-up (95 % CI = 1.85–9.84; p = 0.000). There was no significant relationship between HGS and hospital re-admissions. Conclusions Effects of strength reduction occurring during a period of hospitalization could produce effects even after hospitalization itself. This increases the relevance of maintaining usual physical performance of patients even during hospitalization. Keywords
Hand grip Frailty Strength Elderly
Introduction Physical performances have been associated with different clinical and functional outcomes [1–3]. Low hand grip strength (HGS) in middle-aged and older community dwelling adults is associated with subsequent onset of functional limitations, disability, cognitive decline, co-morbidities and increased all-cause mortality rates [4]. In the acute hospital setting, lower admission HGS was associated with decreased likelihood of discharge home among older acutely ill medical patients and patients hospitalized with pneumonia [5]. But it is still unclear whether a single measure of weak HGS or a decrease in HGS could have the most relevant predictive value. Recent findings reported that the decline in HGS over time represents a strong predictor of several consequences [6]. The most interesting observation made by the authors is that becoming weaker during a specific period of time is more predictive than being weak at a time. The change of HGS could have worst outcomes than a single measure of weak strength. This aspect acquires more relevance in elderly people, usually more susceptible to adverse events. In fact patients
123
634
aged 65 or older are exposed to several agents that could determine poor mobilization or bed rest for a longer time that it would be expected in younger people. Physical immobilization, associated to comorbidity and frailty, concur to reduce the muscular strength. The main outcome of the present study is to recognize possible relationships between a HGS reduction during hospitalization and negative outcomes, such as death or hospital re-admissions at 3-month and 1-year follow-up.
Methods This is an observational study performed in an acute Geriatric Medical Ward. All patients admitted between November 2010 and May 2011 and aged 65 years or more have been evaluated and eventually recruited for the study. Patients with the following characteristics have been excluded: patients not able to answer questions or to follow orders, patients with an APACHE score higher than 20 and a Karnovsky score lower than 70, patients cognitively impaired [SPMSQ (short portable mental status questionnaire) more than three errors], patients affected by hand osteoarthritis. Patient’s characteristics, such as gender, age, activities of daily living (ADL), body mass index (BMI), mini nutritional assessment (MNA), days of hospitalization, have been recorded. The HGS has been evaluated during hospital admission and discharge using a hydraulic dynamometer (Saehan Corp Masan, Korea). Patients enrolled were tested on their main arm, when they were set down, with the arm inflected at 90°. The subject was seated with shoulder adducted and neutrally rotated, elbow flexed at 90°, and the forearm and wrist in neutral position. Each subject was also positioned between 0° and 30° wrist extension and between 0° and 15° of ulnar deviation as well as given standard instructions for participation [7, 8]. The subject was asked to give maximum effort. Each patient was tested during three trials after an example test; the best performance for each patient was collected. HGS was divided into four classes of strength: B12 kg; 13–16 kg; 17–21 kg; C22 kg. Three months after hospital discharge a telephoned follow-up was performed with the aim to detect if patients were still alive or if they underwent one or more new hospital admissions. One year after hospital discharge the same patients were phoned with the aim to know whether they were still alive or not.
Aging Clin Exp Res (2013) 25:633–636
been analyzed using Kaplan–Meier’s curves. The analyses have been adjusted for age and gender. Results A total of 201 hospitalized patients have been recruited: 76 were males and 125 females. The mean age was 81.79 ± 7.409 years. Mean general characteristics of the sample enrolled are reported in Table 1. Most of patients enrolled were admitted to hospital ward for heart (heart failure, atrial fibrillation) and lung (pneumonia, pleural effusion, COPD exacerbation) diseases, respectively, 32 and 23.5 %. HGS recorded at hospital admission was not statistically related with the duration of length of stay, while a reduction of HGS during hospitalization showed a Table 1 General characteristics of the sample N (%) Gender Female Male Age
76 (37.8) 125 (62.2)
B70
20 (10)
71–80
68 (33.8)
81–89
96 (47.8)
C90
17 (8.5)
BMI Underweight
12 (6)
Normal weight
105 (52.2)
Overweight
57 (28.4)
Class I obesity
13 (6.5)
Class II–III obesity
14 (7)
ADL (No. of functions lost) 0
133 (66.2)
1
26 (12.9)
2
14 (7)
3 4
6 (3) 4 (2)
5
10 (5)
6
8 (4)
IADL Independent
91 (45.3)
Partly dependent
72 (35.8)
Totally dependent
38 (18.9)
MNA
Statistical analysis The statistical analysis was performed using SPSS, version 18 for Windows. The v2 test was used to evaluate relationship between HGS and different variables. Threemonth and 1-year survival and hospital re-admissions have
123
Normal nutritional status
129 (64.2)
At risk of malnutrition
64 (31.8)
Malnourished
8 (4)
BMI Body Mass Index, ADL Activities of Daily Living, IADL Instrumental Activities of Daily Living, MNA Mini Nutritional Assessment
Aging Clin Exp Res (2013) 25:633–636
significant relationship with the number of days spent in hospital (p \ 0.001). HGS reduction during the hospitalization was significantly related with age (p = 0.017), BMI (p = 0.001), MNA (p = 0.009) and with the reduction of the ADL (p = 0.029) and the time of hospitalization in days (p \ 0.001). HGS recorded at the time of hospital admission was not significantly related with death during hospitalization (p = 0.309), while patients with strength reduction occurred during the period of hospitalization at 3-month followup have a relative risk of death more than seven times higher than the others (95 % CI 2.74–18.63; p \ 0.01). As reported in Fig. 1, at 3-month follow-up those patients that decreased their HG strength during hospitalization died earlier than those whose strength did not decreased (p = 0.047) (Fig. 1). Same results were observed at 1-year follow-up (95 % CI = 1.85–9.84; p = 0.000) (Fig. 2). Moreover, strength reduction during hospitalization was not statistically related to an increased risk of
635
hospital re-admission during the 3-month follow-up. But patients that decreased their HGS during hospitalization showed a higher probability of re-admission than controls (p = 0.001) (Fig. 3).
Discussion Our results suggest that becoming weak during hospitalization could be considered as a predictive value in terms of death or hospital re-admissions in elderly patients, even for those not functionally compromised at baseline. Effects of HGS reduction occurring during a period of hospitalization could produce effects even after hospitalization itself. As it should be clear and understandable that a strength reduction due to a hospital length of stay can produce effects at 3 months, it appears more unclear how there should be a link between hospital stay and survival at 1 year. It is possible that other not investigated or not known items play a relevant role in terms of survival’s reduction in our population. Maybe that sample observed is not sufficiently high to permit a generalization of results, or that the few number of patients enrolled affects the statistical analysis. Otherwise, it is possible that illnesses or prolonged bed rest shows their effects even after 1 year, but this aspect, in our opinion, requires a deeper analysis. If confirmed by other studies, this finding underline the relevance of taking care of early mobilization of hospitalized elderly people. Death and new hospital admissions are two parameters easy to collect using a telephone follow-up. This is probably the main limit of the study. In fact, a deeper analysis, in particular in terms of functional abilities of daily living, should have been more helpful in order to detect consequences of hospitalizations.
Fig. 1 Cumulative survival at 3-month follow-up (p = 0.047)
Fig. 2 Cumulative survival at 1-year follow-up (p = 0.000)
Fig. 3 Time of hospital re-admission at 3-month follow-up (p = 0.001)
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Aging Clin Exp Res (2013) 25:633–636
Conclusions These findings underline the importance of those clinical and functional practices, such as early mobilization and nutritional evaluation with food supplementation, that should be adopted in all geriatric wards and aiming to preserve patients’ physical performance. Conflict of interest disclose.
The authors have no conflicts of interest to
References 1. Guralnik JM, Simonsick EM, Ferrucci L et al (1994) A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission. J Gerontol 49(2):M85–M94 2. Guralnik JM, Ferrucci L, Simonsick EM et al (1995) Lowerextremity function in persons over the age of 70 years as a predictor of subsequent disability. N Engl J Med 332(9):556–561
123
3. Bohannon RW (2008) Hand-grip dynamometry predicts future outcomes in aging adults. J Geriatr Phys Ther 31(1):3–10 4. Isaia G, Maero B, Gatti A et al (2009) Risk factors of functional decline during hospitalization in the oldest old. Aging Clin Exp Res 21(6):453–457 5. Roberts HC, Syddall HE, Cooper C et al (2012) Is grip strength associated with length of stay in hospitalised older patients admitted for rehabilitation? Findings from the Southampton grip strength study. Age Ageing 41(5):641–646 6. Xue QL, Walston JD, Fried LP et al (2011) Prediction of risk of falling, physical disability, and frailty by rate of decline in grip strength: the women’s health and aging study. Arch Intern Med 171(12):1119–1121 7. Petersen P, Petrick M, Connor H et al (1989) Grip strength and hand dominance: challenging the 10% rule. Am J Occup Ther 43(7):444–447 8. Mathiowetz V, Kashman N, Volland G et al (1985) Grip and pinch strength: normative data for adults. Arch Phys Med Rehabil 66(2):69–74
ORIGINAL ARTICLE
Predictive effects of muscle strength after hospitalization in old patients Gianluca Isaia • Francesca Greppi • Alessandra Pastorino • Erika Maria Bersano Sokol Rrodhe • Nicoletta Aimonino Ricauda • Mario Bo • Katia Molinar Roet • Mauro Zanocchi
•
Received: 6 November 2012 / Accepted: 17 June 2013 / Published online: 23 October 2013 Ó Springer International Publishing Switzerland 2013
Abstract Background and aims Frailty is a common situation that often influences clinical outcomes, disability or institutionalization. The present study aims to evaluate the weight of hand grip strength (HGS) reduction in terms of death or re-hospitalizations, at 3-month and 1-year follow-up. Methods Observational study performed on hospitalized patients aged 65 years or more. The HGS was measured twice: at hospital admission and discharge. The statistical analysis was performed using SPSS, version 18 for Windows. The v2 test was used to evaluate the relationship between HGS and different variables. Three-month and 1-year survival and hospital re-admissions have been analyzed using Kaplan–Meier’s curves. The analyses have been adjusted for age and gender. Results A total of 201 hospitalized patients have been recruited. Of them, 76 were males. The mean age was 81.79 ± 7.409 years. Of all the patients enrolled, 66.2 and 45.3 % did not show any impairment performing activities of daily living and instrumental activities of daily living, respectively. Moreover, patients were not cognitively impaired [SPMSQ (short portable mental status questionnaire ) m ± SD = 1.47 ± 0.794]. At 3-month follow-up patients with strength reduction had a relative risk of death more than seven times higher than the others (p = 0.047).
G. Isaia F. Greppi (&) A. Pastorino S. Rrodhe Geriatric Division, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Regione Gonzole 10, 10043 Orbassano (Turin), Italy e-mail: [email protected] E. M. Bersano N. Aimonino Ricauda M. Bo K. Molinar Roet M. Zanocchi Geriatric Section, Department of Medical and Surgical Disciplines, S. Giovanni Battista Hospital, University of Torino, Turin, Italy
Same results were observed at 1-year follow-up (95 % CI = 1.85–9.84; p = 0.000). There was no significant relationship between HGS and hospital re-admissions. Conclusions Effects of strength reduction occurring during a period of hospitalization could produce effects even after hospitalization itself. This increases the relevance of maintaining usual physical performance of patients even during hospitalization. Keywords
Hand grip Frailty Strength Elderly
Introduction Physical performances have been associated with different clinical and functional outcomes [1–3]. Low hand grip strength (HGS) in middle-aged and older community dwelling adults is associated with subsequent onset of functional limitations, disability, cognitive decline, co-morbidities and increased all-cause mortality rates [4]. In the acute hospital setting, lower admission HGS was associated with decreased likelihood of discharge home among older acutely ill medical patients and patients hospitalized with pneumonia [5]. But it is still unclear whether a single measure of weak HGS or a decrease in HGS could have the most relevant predictive value. Recent findings reported that the decline in HGS over time represents a strong predictor of several consequences [6]. The most interesting observation made by the authors is that becoming weaker during a specific period of time is more predictive than being weak at a time. The change of HGS could have worst outcomes than a single measure of weak strength. This aspect acquires more relevance in elderly people, usually more susceptible to adverse events. In fact patients
123
634
aged 65 or older are exposed to several agents that could determine poor mobilization or bed rest for a longer time that it would be expected in younger people. Physical immobilization, associated to comorbidity and frailty, concur to reduce the muscular strength. The main outcome of the present study is to recognize possible relationships between a HGS reduction during hospitalization and negative outcomes, such as death or hospital re-admissions at 3-month and 1-year follow-up.
Methods This is an observational study performed in an acute Geriatric Medical Ward. All patients admitted between November 2010 and May 2011 and aged 65 years or more have been evaluated and eventually recruited for the study. Patients with the following characteristics have been excluded: patients not able to answer questions or to follow orders, patients with an APACHE score higher than 20 and a Karnovsky score lower than 70, patients cognitively impaired [SPMSQ (short portable mental status questionnaire) more than three errors], patients affected by hand osteoarthritis. Patient’s characteristics, such as gender, age, activities of daily living (ADL), body mass index (BMI), mini nutritional assessment (MNA), days of hospitalization, have been recorded. The HGS has been evaluated during hospital admission and discharge using a hydraulic dynamometer (Saehan Corp Masan, Korea). Patients enrolled were tested on their main arm, when they were set down, with the arm inflected at 90°. The subject was seated with shoulder adducted and neutrally rotated, elbow flexed at 90°, and the forearm and wrist in neutral position. Each subject was also positioned between 0° and 30° wrist extension and between 0° and 15° of ulnar deviation as well as given standard instructions for participation [7, 8]. The subject was asked to give maximum effort. Each patient was tested during three trials after an example test; the best performance for each patient was collected. HGS was divided into four classes of strength: B12 kg; 13–16 kg; 17–21 kg; C22 kg. Three months after hospital discharge a telephoned follow-up was performed with the aim to detect if patients were still alive or if they underwent one or more new hospital admissions. One year after hospital discharge the same patients were phoned with the aim to know whether they were still alive or not.
Aging Clin Exp Res (2013) 25:633–636
been analyzed using Kaplan–Meier’s curves. The analyses have been adjusted for age and gender. Results A total of 201 hospitalized patients have been recruited: 76 were males and 125 females. The mean age was 81.79 ± 7.409 years. Mean general characteristics of the sample enrolled are reported in Table 1. Most of patients enrolled were admitted to hospital ward for heart (heart failure, atrial fibrillation) and lung (pneumonia, pleural effusion, COPD exacerbation) diseases, respectively, 32 and 23.5 %. HGS recorded at hospital admission was not statistically related with the duration of length of stay, while a reduction of HGS during hospitalization showed a Table 1 General characteristics of the sample N (%) Gender Female Male Age
76 (37.8) 125 (62.2)
B70
20 (10)
71–80
68 (33.8)
81–89
96 (47.8)
C90
17 (8.5)
BMI Underweight
12 (6)
Normal weight
105 (52.2)
Overweight
57 (28.4)
Class I obesity
13 (6.5)
Class II–III obesity
14 (7)
ADL (No. of functions lost) 0
133 (66.2)
1
26 (12.9)
2
14 (7)
3 4
6 (3) 4 (2)
5
10 (5)
6
8 (4)
IADL Independent
91 (45.3)
Partly dependent
72 (35.8)
Totally dependent
38 (18.9)
MNA
Statistical analysis The statistical analysis was performed using SPSS, version 18 for Windows. The v2 test was used to evaluate relationship between HGS and different variables. Threemonth and 1-year survival and hospital re-admissions have
123
Normal nutritional status
129 (64.2)
At risk of malnutrition
64 (31.8)
Malnourished
8 (4)
BMI Body Mass Index, ADL Activities of Daily Living, IADL Instrumental Activities of Daily Living, MNA Mini Nutritional Assessment
Aging Clin Exp Res (2013) 25:633–636
significant relationship with the number of days spent in hospital (p \ 0.001). HGS reduction during the hospitalization was significantly related with age (p = 0.017), BMI (p = 0.001), MNA (p = 0.009) and with the reduction of the ADL (p = 0.029) and the time of hospitalization in days (p \ 0.001). HGS recorded at the time of hospital admission was not significantly related with death during hospitalization (p = 0.309), while patients with strength reduction occurred during the period of hospitalization at 3-month followup have a relative risk of death more than seven times higher than the others (95 % CI 2.74–18.63; p \ 0.01). As reported in Fig. 1, at 3-month follow-up those patients that decreased their HG strength during hospitalization died earlier than those whose strength did not decreased (p = 0.047) (Fig. 1). Same results were observed at 1-year follow-up (95 % CI = 1.85–9.84; p = 0.000) (Fig. 2). Moreover, strength reduction during hospitalization was not statistically related to an increased risk of
635
hospital re-admission during the 3-month follow-up. But patients that decreased their HGS during hospitalization showed a higher probability of re-admission than controls (p = 0.001) (Fig. 3).
Discussion Our results suggest that becoming weak during hospitalization could be considered as a predictive value in terms of death or hospital re-admissions in elderly patients, even for those not functionally compromised at baseline. Effects of HGS reduction occurring during a period of hospitalization could produce effects even after hospitalization itself. As it should be clear and understandable that a strength reduction due to a hospital length of stay can produce effects at 3 months, it appears more unclear how there should be a link between hospital stay and survival at 1 year. It is possible that other not investigated or not known items play a relevant role in terms of survival’s reduction in our population. Maybe that sample observed is not sufficiently high to permit a generalization of results, or that the few number of patients enrolled affects the statistical analysis. Otherwise, it is possible that illnesses or prolonged bed rest shows their effects even after 1 year, but this aspect, in our opinion, requires a deeper analysis. If confirmed by other studies, this finding underline the relevance of taking care of early mobilization of hospitalized elderly people. Death and new hospital admissions are two parameters easy to collect using a telephone follow-up. This is probably the main limit of the study. In fact, a deeper analysis, in particular in terms of functional abilities of daily living, should have been more helpful in order to detect consequences of hospitalizations.
Fig. 1 Cumulative survival at 3-month follow-up (p = 0.047)
Fig. 2 Cumulative survival at 1-year follow-up (p = 0.000)
Fig. 3 Time of hospital re-admission at 3-month follow-up (p = 0.001)
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Aging Clin Exp Res (2013) 25:633–636
Conclusions These findings underline the importance of those clinical and functional practices, such as early mobilization and nutritional evaluation with food supplementation, that should be adopted in all geriatric wards and aiming to preserve patients’ physical performance. Conflict of interest disclose.
The authors have no conflicts of interest to
References 1. Guralnik JM, Simonsick EM, Ferrucci L et al (1994) A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission. J Gerontol 49(2):M85–M94 2. Guralnik JM, Ferrucci L, Simonsick EM et al (1995) Lowerextremity function in persons over the age of 70 years as a predictor of subsequent disability. N Engl J Med 332(9):556–561
123
3. Bohannon RW (2008) Hand-grip dynamometry predicts future outcomes in aging adults. J Geriatr Phys Ther 31(1):3–10 4. Isaia G, Maero B, Gatti A et al (2009) Risk factors of functional decline during hospitalization in the oldest old. Aging Clin Exp Res 21(6):453–457 5. Roberts HC, Syddall HE, Cooper C et al (2012) Is grip strength associated with length of stay in hospitalised older patients admitted for rehabilitation? Findings from the Southampton grip strength study. Age Ageing 41(5):641–646 6. Xue QL, Walston JD, Fried LP et al (2011) Prediction of risk of falling, physical disability, and frailty by rate of decline in grip strength: the women’s health and aging study. Arch Intern Med 171(12):1119–1121 7. Petersen P, Petrick M, Connor H et al (1989) Grip strength and hand dominance: challenging the 10% rule. Am J Occup Ther 43(7):444–447 8. Mathiowetz V, Kashman N, Volland G et al (1985) Grip and pinch strength: normative data for adults. Arch Phys Med Rehabil 66(2):69–74
