A predictive index for functional decline in hospitalized elderly medical patients

To prospectively develop and validate a predictive index to identify on admission elderly hospitalized medical patients at risk for functional decline.

Two prospective cohort studies, in tandem. The predictive model developed in the initial cohort was subsequently validated in a separate cohort.

General medical wards of a university teaching hospital.

For the development cohort, 188 hospitalized general medical patients aged > or = 70 years. For the validation cohort, 142 comparable patients.

The subjects and their nurses were interviewed twice weekly using standardized, validated instruments. Functional decline occurred among 51/188 (27%) patients in the development cohort. Four independent baseline risk factors (RFs) for functional decline were identified: decubitus ulcer (adjusted relative risk [RR] 2.7; 95% confidence interval [CI] 1.4, 5.2); cognitive impairment (RR 1.7; CI 0.9, 3.1); functional impairment (RR 1.8; CI 1.0, 3.3); and low social activity level (RR 2.4; CI 1.2, 5.1). A risk-stratification system was developed by adding the numbers of RFs. Rates of functional decline for the low- (0 RF), intermediate- (1-2 RFs), and high- (3-4 RFs) risk groups were 8%, 28%, and 63%, respectively (p < 0.0001). The corresponding rates in the validation cohort, of whom 34/142 (24%) developed functional decline, were 6%, 29%, and 83% (p < 0.0001). The rates of death or nursing home placement, clinical outcomes associated with functional decline in the hospital, were 6%, 19%, and 41% (p < 0.002) in the development cohort and 10%, 32%, and 67% (p < 0.001) in the validation cohort, respectively, for the three risk groups.

Functional decline among hospitalized elderly patients is common, and a simple predictive model based on four risk factors can be used on admission to identify elderly persons at greatest risk.