Changes In Functional Health Status Research Articles

Changes in functional health status following open abdominal aortic aneurysm repair and the role of exercise-based rehabilitation: a systematic review

Background: Physical domains of quality of life measures are negatively impacted following abdominal aortic aneurysm (AAA) repair. This is likely to reflect a reduction in objective measures of functional status, although this is yet to be established. These reductions can be targeted via exercise-based rehabilitation. This review aims to systematically evaluate the current evidence quantifying changes in functional status following open AAA repair and to consider the role of exercise-based rehabilitation for these patients. Methods: The Medline, EMBASE and Cochrane CENTRAL databases were searched using two distinct search strategies. We included all prospective randomised and non-randomised trials that considered the impact of open AAA repair on functional status and/or the effect of exercise-based rehabilitation following open AAA repair. The primary outcomes were changes in objective measures of functional status following AAA repair and changes in these measures following exercise-based rehabilitation. Risk of bias was independently assessed by two review authors using the criteria outlined in the revised Cochrane tool (ROB 2.0) or the risk of bias in non-randomised studies of interventions (ROBINS-I) tool. Results: No studies were identified that quantified changes in functional status following open AAA repair. One study considered exercise-based rehabilitation. This three-arm randomised trial compared two walking-based exercise programmes with routine care physiotherapy.Patients who underwent backward walking-based rehabilitation had a significantly lesser decline in functional status than the other groups, based on the 6-minute walk test and standard metabolic equivalents. There were no significant differences in length of stay or pulmonary function. Discussion: This is the first systematic review to explore the objective decline in functional status and the role of exercise-based rehabilitation following open AAA repair. There is no evidence to quantify functional decline following AAA repair and limited low quality evidence to support exercise-based rehabilitation. The ideal next step for future research would be a feasibility or observational before-and-after cohort study using direct measures of physical function such as the short physical performance battery or the 6-minute walk test.

Personalized Lifestyle Intervention and Functional Evaluation Health Outcomes SurvEy: Presentation of the LIFEHOUSE Study Using N-of-One Tent-Umbrella-Bucket Design.

The working definition of health is often the simple absence of diagnosed disease. This common standard is limiting given that changes in functional health status represent early warning signs of impending health declines. Longitudinal assessment of functional health status may foster prevention of disease occurrence and modify disease progression. The LIFEHOUSE (Lifestyle Intervention and Functional Evaluation-Health Outcomes SurvEy) longitudinal research project explores the impact of personalized lifestyle medicine approaches on functional health determinants. Utilizing an adaptive tent–umbrella–bucket design, the LIFEHOUSE study follows the functional health outcomes of adult participants recruited from a self-insured employee population. Participants were each allocated to the tent of an all-inclusive N-of-one case series. After assessing medical history, nutritional physical exam, baseline functional status (utilizing validated tools to measure metabolic, physical, cognitive, emotional and behavioral functional capacity), serum biomarkers, and genomic and microbiome markers, participants were assigned to applicable umbrellas and buckets. Personalized health programs were developed and implemented using systems biology formalism and functional medicine clinical approaches. The comprehensive database (currently 369 analyzable participants) will yield novel interdisciplinary big-health data and facilitate topological analyses focusing on the interactome among each participant’s genomics, microbiome, diet, lifestyle and environment.

Changes in functional health status following open abdominal aortic aneurysm repair and the role of exercise-based rehabilitation: protocol for a systematic review and meta-analysis

Background and objectives: The aim of this systematic review is to explore the current evidence surrounding the changes in functional status following open or endovascular abdominal aortic aneurysm (AAA) repair and the role of postoperative exercise-based rehabilitation programmes. Methods: The proposed study will incorporate two separate systematic reviews within it, one to assess changes in functional status (component 1) and another to consider the role of exercise-based rehabilitation for improving functional status (component 2), both following AAA repair. The Medline, EMBASE and Cochrane CENTRAL databases will be searched using two separate search strategies including the terms “aortic aneurysm”, “functional capacity”, “functional decline” and” exercise therapy”. We plan to include all prospective randomised and non-randomised trials that have considered the impact of AAA repair on functional status and/or the effect of exercise-based rehabilitation following AAA repair. For component 1, the primary outcome will be changes in objective measures of functional capacity or physical function following AAA repair and, for component 2, it will be changes in physical function or functional capacity following exercise-based rehabilitation after AAA repair. The extracted data will include study characteristics – ie, sample size, a description of the intervention and control conditions (where applicable), outcome measures, length of follow-up and main findings related to outcome measures. For both components a narrative synthesis will be produced, supported by a summary table. We intend to conduct quantitative meta-analyses for both components. For each selected outcome we plan to evaluate the certainty of evidence based on the GRADE approach and risk of bias of included studies will be assessed using the Cochrane tool. Conclusions: Based on a lack of current evidence, we present a protocol for a systematic review to investigate the functional changes associated with open and endovascular AAA repair and the potential value of postoperative exercise rehabilitation.

Editor's Foreword

Welcome to the fifth issue of the Journal of Vascular Societies Great Britain and Ireland (JVSGBI). We are really delighted with the success of the journal, and this issue marks the first anniversary of the launch at the Vascular Societies GB&I Annual Scientific meeting last year. The increasing interest in the JVSGBI has been demonstrated by the growing number of submitted articles and the impressive website stats (over 3,000 views). This issue includes three editorials. The first by Andrew Garnham (VSGBI President Elect) and Rachael Forsythe (Rouleaux President) provides a thoughtful reflection on the problem of bullying, undermining and harassment in (vascular) surgical training highlighted as a persistent problem by a Rouleaux Club paper in this edition. The second editorial from Dr Una Adderley, National Wound Care Strategy Programme (NWCSP) Director, outlines past achievements and future plans for the programme. Finally, Duygu Yenidogan-Schmidt, Chair of the Executive Committee of AAA UK, a newly formed patient representative group giving national representation to AAA patients and relatives, highlights the origins, purpose and aims of this group. I am sure these editorials will be of great interest to readers. There are four original research articles, the first from the Rouleaux Club, the UK Vascular Surgery Trainees’ Association, reports the findings from their recent bullying, undermining and harassment survey. The second from the Vascular and Endovascular Research Network (VERN) reports the findings from the Tier 3 COVID-19 Vascular Service (COVER) study. The final two original articles present the findings from the James Lind Alliance Priority Setting Partnership from the Vascular Services and Venous Conditions Groups. It is fantastic to see vascular trainees continuing to undertake meaningful and impactful research and choose the JVSGBI to disseminate their work. This edition also contains a research protocol from Ravindhran et al for a systematic review which aims to study changes in functional health status following open abdominal aortic aneurysm repair. Finally, in this issue there is a short educational report entitled ‘Intraoperative management of REBOA’ and a case report entitled ‘Carotid web: an important cause of stroke in young people’. The National Wound Care Strategy Programme Guidelines for lower limb wounds are published as a supplement to this issue and can be located on the journal website. This is our fifth issue, and we would like to take the opportunity to thank all the authors who have submitted articles during the last year, which is building on the success of the journal – your contribution has been really appreciated and I hope you are delighted with your publication. We would also like to thank all the reviewers for their timely and thorough contributions. Finally, please do continue to share your work by submitting articles for publication.

Evaluation of Postoperative Functional Health Status Decline Among Older Adults

Functional outcomes have value for older adults who undergo surgical procedures. Preventing postoperative functional decline in this patient population necessitates the identification of the factors associated with this outcome and minimizing their implications. To assess the prevalence of functional decline 30 days after a surgical procedure among older adults 80 years or older, examine the risk factors of this decline, and identify ways to minimize this decline by addressing its mutable factors. This retrospective cohort study used patient data from the Geriatric Surgery Pilot Project, a multi-institutional data registry of the American College of Surgeons National Surgical Quality Improvement Program. Inclusion criteria were patients 80 years or older who underwent a surgical procedure that required an inpatient stay at 1 of 23 hospitals enrolled in the Geriatric Surgery Pilot Project from January 1, 2015, to December 31, 2018, and had preoperative and postoperative functional health status data. Data analysis was performed from January 7, 2019, to December 2, 2019. Adults 80 years or older who underwent an inpatient surgical procedure. The primary outcome was 30-day postoperative functional decline defined by a change in functional health status from admission or before the surgical procedure (ie, from independent to partially or totally dependent, or from partially dependent to totally dependent). Functional health status was measured by a patient's ability to perform activities of daily living. Secondary outcomes were hospital readmission and 30-day postoperative living location. Of the 2013 patients analyzed in this study, 1128 were women (56.0%) and the mean (SD) age was 84.9 (3.9) years. Functional decline at 30 days after the surgical procedure was present in 406 patients (20.2%). Prevalence of this outcome increased with age, with 337 of 1751 patients aged 80 to 89 years (19.2%) experiencing decline compared with 69 of 262 patients 90 years or older (26.3%). In a risk-adjusted model, the geriatric-specific risk factors statistically significantly associated with this outcome included preoperative mobility aid use (odds ratio [OR] 1.76; 95% CI, 1.39-2.22; P < .001) and malnutrition (OR, 1.88; 95% CI, 1.04-3.43; P = .04) as well as postoperative delirium (OR, 2.20; 95% CI, 1.60-3.02; P < .001), pressure ulcer (OR, 1.83; 95% CI, 1.02-3.30; P = .04), and mobility aid at discharge (OR, 2.49; 95% CI, 1.72-3.59; P < .001). Among patients with a 30-day functional decline, 106 (26.1%) required hospital readmission and only 219 (53.9%) were living at home compared with 388 patients (95.6%) living at home before the procedure. In this study, 1 in 5 older adults experienced a functional decline that persisted 30 days after a surgical procedure, an outcome that appeared to be associated with several geriatric-specific risk factors. Future trials are needed to evaluate whether the prevention or mitigation of these factors can decrease the rates of postoperative functional decline in this patient population.

Predictors of Change in Functional Health Status in Adults with Repaired Tetralogy of Fallot.

Left ventricular (LV) ejection fraction (EF) and right ventricular (RV) ejection fraction by cardiovascular magnetic resonance (CMR) are associated with functional health status in patients with repaired tetralogy of Fallot (TOF) in cross-sectional studies, but few longitudinal data are available. This study aimed to determine predictors of subsequent decrease in functional health status in midterm follow-up. Patients with repaired TOF who had previously completed CMR and assessment with the Short Form 36 version 2 (SF-36) were recruited for repeat CMR, SF-36, and exercise test, if they had not had interval pulmonary valve replacement (PVR). Patients from the same cohort who had undergone PVR were recruited for repeat SF-36. A total of 19 patients (median 33.5years old, interquartile range [IQR] 26-42years, 53% male) had not undergone PVR and were enrolled at a median of 5.0years (IQR 4.8-5.3) since prior CMR and SF-36. LVEF and RVEF did not change from baseline, while RV end-diastolic volume increased (138±34 vs. 126±31ml/m(2), p=0.02). In the overall cohort, SF-36 scores remained stable. However, higher baseline RV end-systolic volume and pulmonary regurgitant fraction correlated with subsequent decreases in SF-36 scores. In 9 patients post-PVR (median 35.9years old, IQR 24-43), physical functioning increased compared to those without PVR (change in z-score +0.59±0.59 vs. -0.26±0.72, p=0.005). In adults with repaired TOF who do not undergo PVR, LVEF, RVEF, and functional health status remain stable in midterm follow-up. However, baseline RV end-systolic volume correlates with subsequent change in functional health status, underscoring its importance in prognostication and timing of intervention in this population.

Predictors of change in functional health status in adults with repaired tetralogy of Fallot

Left ventricular (LV) ejection fraction (EF) and right ventricular (RV) ejection fraction by cardiovascular magnetic resonance (CMR) are associated with functional health status in patients with repaired tetralogy of Fallot (TOF) in cross-sectional studies, but few longitudinal data are available. This study aimed to determine predictors of subsequent decrease in functional health status in midterm follow-up. Patients with repaired TOF who had previously completed CMR and assessment with the Short Form 36 version 2 (SF-36) were recruited for repeat CMR, SF-36, and exercise test, if they had not had interval pulmonary valve replacement (PVR). Patients from the same cohort who had undergone PVR were recruited for repeat SF-36. A total of 19 patients (median 33.5 years old, interquartile range [IQR] 26–42 years, 53 % male) had not undergone PVR and were enrolled at a median of 5.0 years (IQR 4.8–5.3) since prior CMR and SF-36. LVEF and RVEF did not change from baseline, while RV end-diastolic volume increased (138 ± 34 vs. 126 ± 31 ml/m2, p = 0.02). In the overall cohort, SF-36 scores remained stable. However, higher baseline RV end-systolic volume and pulmonary regurgitant fraction correlated with subsequent decreases in SF-36 scores. In 9 patients post-PVR (median 35.9 years old, IQR 24–43), physical functioning increased compared to those without PVR (change in z-score +0.59 ± 0.59 vs. −0.26 ± 0.72, p = 0.005). In adults with repaired TOF who do not undergo PVR, LVEF, RVEF, and functional health status remain stable in midterm follow-up. However, baseline RV end-systolic volume correlates with subsequent change in functional health status, underscoring its importance in prognostication and timing of intervention in this population.

The Relationship of Patient Medical and Laboratory Characteristics to Changes in Functional Health Status in Children and Adolescents After the Fontan Procedure

Despite hypothesized concerns about deterioration beginning in adolescence, longitudinal data and associated factors regarding standardized assessment of physical functioning are not available for Fontan patients. Parents who participated in the Fontan Cross-Sectional Study completed the Child Health Questionnaire at 2 time points for 245 subjects ages 6-18 years. Associations between change in Physical Functioning Summary Score and baseline patient, medical, and laboratory characteristics (mean age 9.5 ± 1.7 years) and follow-up patient and medical characteristics (mean age 16.2 ± 1.6 years) were determined by regression analyses. During a mean of 6.7 ± 0.4 years, a small (not clinically important) but statistically significant decrease in score from 46.2 ± 11.7 to 44.5 ± 12.1 (p < 0.03) was noted. Subjects with higher baseline scores had a greater decrease in score (r = -0.48; p < 0.001). A multivariable model of patient and medical characteristics (R(2) = 0.11) showed that a greater decrease in score was significantly associated with interim development of asthma (n = 13; parameter estimate [PE] -6.6; p < 0.05) or other chronic respiratory, lung, or breathing problems (n = 13; PE -12.5; p < 0.001) and the presence of protein-losing enteropathy at any time (n = 12; PE -9.4; p = 0.006). Change in score was not significantly associated with baseline laboratory measures of exercise capacity and ventricular characteristics and function. Therefore, although physical functioning may be stable during adolescence for many Fontan patients, deterioration occurs in some in association with respiratory conditions and protein-losing enteropathy. Further longitudinal study is necessary to better understand the relationship between clinical morbidities and functional health status as these patients transition into adulthood.

Functional health status and its relationship to depressive personality disorder, dysthymia, and major depression: preliminary findings

Controversy continues on the extent to which depressive personality disorder (DPD) and dysthymic disorder (DYST) may be differentiated. Although affective disorders often are accompanied by changes in functional health status, to date no study has examined how functional health associated with affective disorders may assist in differentiating the two disorders. In this study, we hypothesized that measures of DPD would have fewer correlations with functional health status than would measures of DYST and major depressive disorder (MDD). African American women (n=110) completed questionnaires that assessed for depressive disorders, somatic concerns, and physical health. Measures of DPD, DYST, and MDD were all significantly correlated with functional health status. When symptoms of MDD were controlled, DYST was more associated with functional health status than was a DSM-IV measure of DPD, although a self-report measure of DPD--the Depressive Personality Disorder Inventory [DPDI; Huprich et al., 1996: J Clin Psychol 52:152-159]--remained significantly correlated with functional health status. When symptoms of DYST were controlled, DSM-IV symptoms of DPD were not strongly associated with functional health status, although measures of MDD and the DPDI were correlated with functional health status. We concluded that despite the overlap in depressive symptoms and functional health status, DPD may be less associated with functional health status in a primary care population than DYST and MDD. Implications for the assessment of DPD are provided.

Living arrangements, social integration, and change in functional health status.

Limited prospective data have examined the association between living arrangements and emotional wellbeing. The authors assessed whether older women living with a spouse were less likely to experience a decline in mental health, vitality, or physical function compared with women living alone or with nonspouse others. The association between living arrangement and 4-year change in functional health status was examined prospectively among 28,324 women aged 60-72 years in the Nurses' Health Study. After adjustment for age, baseline function, comorbid conditions, and health behaviors, women living alone had lower risk of decline in mental health (relative risk (RR) = 0.73, 95 percent confidence interval (CI): 0.65, 0.81) and vitality (RR = 0.72, 95 percent CI: 0.65, 0.80) compared with those living with a spouse. Contact with friends and relatives and level of social engagement were significantly protective against a decline in mental health among women living alone but not among women living with a spouse. These results suggest that women living independently are neither socially isolated nor at increased risk for decline in functional health status. In fact, these women actually fare better on measures of psychologic function than do women living with a spouse.

Effects of functional decline on quality of life among the Japanese elderly.

The effects of functional decline upon social networks, life satisfaction, and depression were observed and statistically tested in a longitudinal prospective design. Subjects were 692 Japanese elderly, aged sixty-five years or older, with high functional capacity at baseline. During a two-year period of follow-up, 12.3 percent of the subjects experienced functional decline. Repeated-measure analyses of covariance with statistical tests for simple main effects revealed that changes in the criterion variables significantly differed along with changes in functional health status when the effects of age, gender, and socioeconomic status were controlled. The subjects who experienced functional decline showed a larger decrease in the number of relatives, friends, and neighbors having frequent contacts, a larger decline in life satisfaction, and a larger increase in depression than those without functional decline. The results seem to confirm further the importance of functional health status as a prerequisite for higher quality of life in old age.

Prospective study on the relation between living arrangement and change in functional health status of elderly women.

Limited prospective data exist on how living arrangements are associated with change in functional health. This study evaluated whether elderly women living alone were less likely to experience functional decline when compared with women who lived with others. A total of 619 community-dwelling, white women from Baltimore, Maryland, aged 65-99 years at baseline were questioned annually from 1984 to 1986. Functional health was measured as the sum of limitations in seven physical and seven instrumental activities of daily living (Instrumental ADL). A total of 148 women experienced functional decline over the 2 years, primarily as a deterioration in Instrumental ADL. The association between living arrangement and change in Instrumental ADL depended on the level of physical impairment. Among women without severe impairment, Instrumental ADL deterioration was significantly less for those living alone compared with those living with spouses (odds ratio (OR) = 0.60, 95% confidence interval (CI) 0.45-0.92) or nonspouse others (OR = 0.62, 95% CI 0.45-0.96). For women with severe impairment, however, those living alone had a greater decline in Instrumental ADL, especially when compared with those living with nonspouse others (OR = 5.13, 95% CI 1.23-21.28). These results suggest that, unless severely physically impaired, women living independently have less deterioration in functional health when compared with peers in alternate living arrangements.

The evaluation of changes in functional health status in patients with abdominal complaints

Measuring functional status changes in various patient subgroups is important in stratifying risk, assessing disease severity, and predicting and defining clinically relevant outcomes. Data from a multicentered study of 980 primary care patients presenting with nonspecific abdominal complaints were studied to demonstrate the importance of such an assessment procedure. Patients were prospectively followed for 6 months. Five diagnostic categories based on illness duration and seriousness were derived from the clinical course of these patients. The functional status of each patient was determined at baseline, 1 month, and 6 months using the Sickness Impact Profile (SIP). Intraclass correlation coefficients accounted for two aspects of the reliability of the SIP regarding the measurement of change over time: differences between patients which are stable over time (reproducibility) and different effects of treatment between subsets (responsiveness). A priori formulated expectations about the degree of health status change in patient subgroups were evaluated with the help of effect—size calculations. Patient impairment only partially depended on the final diagnosis and was also influenced by the presence of co-morbidity, psycho-social determinants, and other complaints. The health status change in the patient subgroups agreed with a priori formulated expectations. Standardized effect—size calculations revealed that the degree of change over time in SIP scores was in accordance with these expectations. We conclude: (a) the SIP appeared to be a reliable clinimetric instrument in detecting change over time resulting from different clinical courses, (b) clinical studies that use clinimetric instruments to assess the effects of clinical interventions must adequately control for the influence of baseline “functional status” as well as traditional demographic features such as gender and age, and (c) evaluating a priori formulated clinical expectations concerning functional change with statistics such as intraclass correlation and effect sizes can lead to a clearer understanding of the clinical relevance of statistically significant changes.

Remote monitoring of health status of the elderly at home. A multidisciplinary project on aging at the University of New South Wales.

This paper discusses the design and implementation of a multidisciplinary research project and associated field trials to test the hypothesis that functional health status amongst the elderly can be accurately determined remotely by continuously monitoring relatively simple parameters that measure the interaction between participants and their environment. In this study we propose that changes in such simple measures as mobility, sleep patterns, and utilisation of cooking, washing and toilet facilities, can identify changes in functional health status. One of the primary end goals of the project will be to automatically prompt appropriate, timely and cost-effective intervention of medical and community based services to help reduce morbidity and maintain an independent high quality of life for the elderly. Targeted intervention will diminish the demand for high cost medical services. This will have large potential economic implications in helping to contain and reduce the increasing cost of providing health care services to the aged.