Functional Recovery in Hospitalized Elderly Adults

Abstract

To the Editor: We read with much interest the study by Baztán et al., 1 which identified the predictors of functional recovery during hospitalization for acute medical diseases in elderly adults. This observation is of substantial value because it confirms, clarifies, and summarizes the results of two recent studies, one in Italy2 and the other in Australia.3 While investigating the predictors of in-hospital functional recovery after a preadmission acute decline, Baztán et al.1 properly performed separate analyses for complete in-hospital recovery (being discharged with baseline functional level of 15 days before admission) and partial recovery (functional improvement not great enough to allow the individual to be discharged at the baseline, premorbid level). For complete in-hospital recovery, the association between the extent of preadmission decline and inability to achieve complete functional recovery during hospitalization is somewhat obvious, because if an individual experiences a large preadmission decline, he or she is unlikely to fully regain his or her premorbid functionality during the limited time of hospital stay.3 Partial in-hospital recovery deserves, in our opinion, more consideration. Similar to the results of one of the previous studies,2 in the observation by Baztán et al.,1 individuals with partial functional improvement had two distinctive and seemingly contrasting features: they had greater preadmission decline, but also higher baseline functional level. Thus, although greater preadmission decline is negatively associated with complete recovery, it is positively associated with partial recovery.1-3 A large pre-admission decline reflects greater vulnerability to the stress of the acute illness and predicts negative outcomes,4 but when the coexistence of high premorbid function mitigates this condition of “frailty,” then there is a “resilient” effect during hospitalization (functional improvement proportional to the previous preadmission decline).1, 2 In the Progetto Dimissioni in Geriatria Study, 35.9% of participants who experienced a preadmission functional decline had fully regained baseline functional status at hospital discharge, 23.1% improved partially but did not fully recover, 39.7% remained stable, and only 1.3% declined further during hospitalization.2 A full recovery to baseline level is typical of individuals with good premorbid characteristics (younger age, baseline independence, low comorbidity, limited preadmission decline)5 and is supposed to occur independently of the quality of hospital management; to the contrary, individuals with dramatic preadmission decline but high baseline level of function may represent an intermediate category between “frail” and “fit” individuals, who may undergo only partial, yet precious, improvements during hospitalization. These individuals are presumably those who may benefit more from specific geriatric interventions aimed at improving functional outcomes during the hospital stay. Thus, if acute illnesses and subsequent hospitalization account for nearly half of all new cases of disability in elderly persons,6 “resilience” should be emphasized much more than “frailty,” with the aim of identifying phenotypes of individuals who may be most likely to recover in response to geriatric interventions during hospitalization. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Both authors contributed equally to the preparation of this manuscript. Sponsor's Role: None.