Hospitalization-Associated
Disability
KENNETH E. COVINSKY, MD, MPH; EDGAR
PIERLUISSI, MD; C. BREE JOHNSTON, MD,
MPH. JAMA. 2011;306(16):1782-1793
Ryan Mullins MS-III
Mercer University School of Medicine
Dr. Rahimi- RTR Medical Group
Savannah, GA
12/1/2011
Purpose of Discussion
 In geriatric patients, acute medical illness requiring
hospitalization often precipitates disability, resulting in
an inability to live independently and complete basic
activities of daily living(ADLs).
 With an incidence of approximately 1/3 of hospitalized
patients over the age of 70, hospitalization-associated
disability(HAD) represents a problem that must be
addressed.
 This article presents a case of a 70 year old female who
developed HAD and explores: risk factors and risk
stratification tools that identify geriatric patients at
increased risk of HAD; processes that may encourage
HAD and models of care developed to prevent it; and
methods clinicians can use to improve quality of life in
geriatric patients who develop HAD.
Case
 HPI: Ms. N is a 70 y.o. female who presented to the ED with left
labial pain and hematuria for 3 days.
 PMH: DMII, HTN, chronic kidney disease, CAD, PVD, and diabetic
neuropathy.
 SH: Ms. N emigrated from the Philippines in 1997. She was
separated from her husband. Prior to admission, she lived
independently in a friend’s home and was able to perform all of her
ADLs until 3 days before admission. Her monthly income was
$300/month from U.S. Social Security Administration.
 PE: T: 98.2 BP: 155/42 mm Hg P: 55/min RR: 22/min
Ms. N appeared frail and shivering. She had a tender, indurated 3 cm
mass in the left labium majorum. She was AAO X3 and walked with a
normal gait.
 Lab studies: serum creatinine=10.8 mg/dL; K+=8.3 mEq/L;
Hct=19.9%; albumin=3.2 g/dL.
Case Continued- Hospitalization Course
 Day 1- Hemodialysis(HD) was started, and Ms. N received empirical
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treatment for a UTI.
Day 3- I&D of labial lesion. Ms. N was transferred to acute care for
elders(ACE) unit.
While on ACE unit, Ms. N’s nurse noticed that Ms. N had myoclonus of her
extremities, which resulted in difficulty of patient transferring from bed to
commode. Mini-Cog screen at that time was negative. The ACE team
discontinued Gabapentin at this time, which was started after admission
for diabetic neuropathy. 5 days later, myoclonus had resolved, and Ms. N
was again independent in ADLs and walking independently using a walker.
Ms. N continued having HD 3 times weekly. She was transferred from ACE
unit to general medical ward while awaiting outpatient HD slot.
Over the next two weeks while on the general medical ward, Ms. N
developed progressively worsening difficulty ambulating. Even using a
walker, her gait was slow and unsteady. She began needing help using the
commode and bathing.
Day 30- Ms. N was discharged to a skilled nursing facility.
HAD- Incidence
 HAD- “loss of ability to complete 1 of the basic ADLs needed
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to live independently without assistance: bathing, dressing,
rising from bed or a chair, using the toilet, eating, or walking
across a room.”
HAD develops between the onset of the acute illness and d/c
from hospital.
Of patients over the age of 70 hospitalized for a medical
illness, at least 30% are discharged from the hospital with an
ADL disability that they did not have prior to becoming
acutely ill.1,2,3,4
“Approximately 50% of disability among older adults occurs
in the setting of medical hospitalization.”1,5
One year post-discharge, less than 50% of geriatric patients
have returned to baseline levels of functioning.1,6,7
HAD- Risk Factors
Prevention of HAD
Physician’s Role in Preventing HAD
Incorporating Prevention of HAD
Incorporating Prevention of HAD
Table 5. Processes of Hospitalization That May Lead to Hospitalization-Associated
Disability and Quality Improvement Interventions From Acute Geriatric Units.
Covinsky, K. E. et al. JAMA 2011;306:1782-1793
Effect of Disability After the Hospitalization
 Whether a patient suffering from HAD will be able to live
at home after being discharged depends on the patient’s
capacity, social support, resources, and environment.
 Planning a geriatric patient for discharge should include
assessing ability to perform ADLs alone or with available
assistance.
 A home equipment evaluation for patients with new
disabilities might be necessary to make sure patient’s
home is safe (e.g.- stairs, showers, etc.).
 Patient’s ability to understand medication instructions
should be assessed.
Prognosis of HAD
 “In a study of older adults who had developed hospitalization-associated
disability, 41% died by 1 year, 29% remained disabled at 1 year, and only 30%
returned to their preillness level of function.”1,6
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