Impact of hospitalization in functional and mobility capacity of older adults

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(1)MINISTÉRIO DA EDUCAÇÃO UNIVERSIDADE FEDERAL DO RIO GRANDE DO NORTE CENTRO DE CIÊNCIAS DA SAÚDE PROGRAMA DE PÓS-GRADUAÇÃO EM CIÊNCIAS DA SAÚDE. Impact of hospitalization in functional and mobility capacity of older adults Impacto da hospitalização na capacidade funcional e mobilidade de idosos. KARLA VANESSA RODRIGUES SOARES MENEZES. Natal/RN 2017.

(2) KARLA VANESSA RODRIGUES SOARES MENEZES. Impact of hospitalization in functional and mobility capacity of older adults Impacto da hospitalização na capacidade funcional e mobilidade de idosos. Thesis presented to the PostGraduation Program in Health Science of the Federal University of Rio Grande do Norte as a requirement for obtaining a Doctorate degree degree in Health Sciences.. Supervisor: PhD. Ricardo Oliveira Guerra Co-supervisor: PhD. Claudine Auger. Natal/RN 2017.

(3) Universidade Federal do Rio Grande do Norte - UFRN Sistema de Bibliotecas - SISBI Catalogação de Publicação na Fonte. UFRN - Biblioteca Setorial do Centro Ciências da Saúde - CCS Menezes, Karla Vanessa Rodrigues Soares. Impact of hospitalization in functional and mobility capacity of older adults / Karla Vanessa Rodrigues Soares Menezes. - Natal, 2017. 143f.: il. Tese (Doutorado em Ciências da Saúde)-Programa de Pós-Graduação em Ciências da Saúde, Centro de Ciências da Saúde, Universidade Federal do Rio Grande do Norte. Orientador: Prof. PhD. Ricardo Oliveira Guerra. Coorientador: Profa. PhD. Claudine Auger.. 1. Mobility limitation - Tese. 2. Aged - Tese. 3. Hospital - Tese. 4. Functioning - Tese. I. Guerra, Ricardo Oliveira. II. Auger, Claudine. III. Título. RN/UF/BSCCS. CDU 796.. iii.

(4) MINISTÉRIO DA EDUCAÇÃO UNIVERSIDADE FEDERAL DO RIO GRANDE DO NORTE CENTRO DE CIÊNCIAS DA SAÚDE PROGRAMA DE PÓS-GRADUAÇÃO EM CIÊNCIAS DA SAÚDE. Coordinator of Post-graduation Program in Health Science Professor PhD Eryvaldo Socrates Tabosa do Egito. iv.

(5) KARLA VANESSA RODRIGUES SOARES MENEZES. Impact of hospitalization in functional and mobility capacity of older adults Impacto da hospitalização na capacidade funcional e mobilidade de idosos. Approved in ____/____/_____. Examination board:. President of the board:. Members of the board:. v.

(6) DEDICATORY (in Portuguese). Dedico esse trabalho aos meus amados pais Air e Regina que me deram a vida e me ensinaram a lutar pelos meus objetivos. Ao meu esposo Weslley por me amar e prover suporte nessa jornada. Aos meus bens mais preciosos – meus filhos Anna Letícia e Miguel pelo amor incondicional.. vi.

(7) ACKNOWLEDGEMENTS (in Portuguese) Primeiramente agradeço a Deus por me abençoar e proteger todos os dias e permitir que eu siga caminhando e alcançado meus objetivos. A fé em Ti me fez crer nessa vitória.. Aos meus queridos Pais - Air e Regina por me apoiarem incondicionalmente, por me incentivarem a crescer e me mostrarem que eu sou capaz de fazer tudo e conquistar o impossível.. Ao meu querido esposo Weslley por sempre acreditar em mim e se orgulhar de todas as minhas conquistas, pelo seu carinho e companheirismo. Obrigada por abrir mão de sua vida profissional para me acompanhar no meu sonho de morar no exterior e compartilhar comigo essa experiência única.. Aos meus amados filhos Anna Letícia e Miguel por me mostrarem o amor mais belo e puro, por mesmo pequenos entenderem que mamãe precisava estudar para virar “mamãe doutora”. Amo vocês infinitamente.. A minha irmã que mesmo distante compartilha das minhas vitórias e sente orgulho da irmã mais velha.. Aos meus sogros Walney e Mônica e meu cunhado Willyam por me tratarem como uma filha e vibrarem com minhas conquistas.. Ao. meu. orientador prof.. Ricardo. Guerra. por todo. o conhecimento. compartilhado ao longo desses 13 anos de orientação. Obrigado por confiar a mim a oportunidade de desenvolver esse trabalho tão importante. A mais profunda gratidão por tudo.. A minha co-orientadora Claudine Auger por me acolher em Montréal, me ensinar e por sempre estar disponível pra mim e pra minha família. Agradeço por partilhar comigo desse crescimento profissional e pessoal. Aprendi muito nesse ano em que fui sua aluna da Universidade de Montreal. vii.

(8) Aos professores componentes da banca pela disponibilidade e pelas contribuições e considerações pertinentes para com esse trabalho.. A todos os idosos que participaram da pesquisa e que mesmo em um momento delicado de suas vidas se dispuseram a responder e realizar os mais diversos testes. Sem vocês nada disso teria sido possível.. Aos meus bolsistas, um verdadeiro batalhão, que me ajudaram nas coletas 7 dias por semana por 1 ano e 4 meses consecutivos. Um agradecimento especial as bolsistas Ana Cláudia, Joelma e Etielma que me ajudaram de for exemplar.. A minha chefe Ivânia e minhas colegas de trabalho Sayonara e Marília por apoiarem meu afastamento do trabalho e torcerem por mim. A direção do HUOL por me proporcionar a oportunidade de qualificação e a todos os funcionários a sua maneira contribuíram para a realização dessa pesquisa.. A CAPES por me proporcionar uma bolsa de doutorado sanduiche auxiliando a enriquecer meus conhecimentos ao longo desse doutorado.. A Juliana Fernandes por sua infinita paciência em responder meus e-mails e por me ajudar nas mais diversas horas e a todos do laboratório 7 de Geriatria.. Agradeço, enfim, a todos aqueles que de uma forma ou de outra participaram desse projeto e ajudaram a enriquecê-lo.. viii.

(9) “And, when you want something, all the universe conspires in helping you to achieve it” Paulo Coelho. ix.

(10) Abstract Introduction: As people get older, it remains a challenge maintaining functional capacity. Functioning consists of the ability to perform self-care activities (i.e. activities of daily living - ADLs) classified inside the level of “activity and participation” of the International Classification of Functioning, Disability and Health (ICF). Previous studies have identified different risk factors for worsening functional. capacity. during. hospitalization,. including. older. age,. sociodemographic characteristics, pre-existing impairment, cognitive loss, delirium, and comorbidity. In-hospital mobility has received particular attention due to its important association to loss of functional capacity. Few studies about hospitalization effects on older adults have been done in Brazil. Identifying older adults at risk for loss in functional capacity during hospitalization will help researchers and clinicians in order to make informed decisions. Objectives: This study contemplates three objectives: first, to provide an updated review to identify and appraise relevant instruments for measuring older adults’ mobility based on the ICF conceptual framework in the context of an acute care or intensive geriatric rehabilitation unit, and to appraise and compare their measurement properties; second, to evaluate if in-hospital mobility assessed at admission is predictive of loss in functional capacity during hospitalization of older adults and to verify if other variables combined with in-hospital mobility can better predict loss in functional capacity; third, to assess functional changes of hospitalized older adults from pre-admission (baseline) until discharge and identify predictors of loss in functional capacity. Methods: This cohort prospective study was conducted at the Onofre Lopes University Hospital (HUOL), Natal/RN, Brazil, between January 1, 2014 and April 30, 2015. The study enrolled all consecutive patients aged 60 years and older who were acutely admitted and met the following inclusion criteria: 1) ability to provide informed consent; 2) admitted directly from the community; 3) screening for study eligibility performed in the first 24 hours of admission. Independent variables included personal characteristics, domestic living activities (i.e. instrumental activities of daily living – IADL) evaluated by Lawton and Brody’s scale, cognition evaluated by Leganés cognitive test, depression assessed by Geriatric Depression Scale (GDS-15), and in-hospital mobility evaluated by the Short Physical Performance Battery (SPPB). The dependent variable of x.

(11) functional capacity was assessed by the Katz scale. These instruments were applied at two different times: at admission (first 24 hours) and at discharge (1224 hours before). Analysis included descriptive statistics, bivariate and multivariate analysis by means of frequencies, means ± standard error, receiver-operating. characteristic. (ROC),. logistic. binary. regression. and. Generalized Estimating Equation (GEE). Data were entered into the Statistical Package for Social Sciences (SPSS) version 18.0 for Windows. Results: From the 1256 included at discharge, 65 (5.1%) died during hospitalization, thus the final sample consisted of 1191 older adults. The mean age was 70.02 (±7.34) and mean length of hospital stay was 7.65 days (±9.94). Our sample had a high prevalence of surgery (70.1%). Regarding the best instruments to assess mobility, the De Morton Mobility Index (DEMMI) and SPPB presented the best balance between mobility coverage, measurement properties and applicability to acute care and intensive geriatric rehabilitation units. A SPPB cutoff point of 6.5 (62% sensitivity, 54% specificity) identified 593 (49.8%) patients at risk for loss in functional capacity. In logistic regression, SPPB alone presented a statistically significant prediction loss of functional capacity between admission and discharge. Finally, regarding changes in functional capacity, 52.5% of the older adults were discharged with worse functional capacity than baseline. Being dependent for domestic life activities, presence of depression symptons, low levels of cognition and in-hospital mobility were risk factors for greater loss in functional capacity after a hospitalization event. Conclusion: We conclude that DEMMI and SPPB were the best instruments to assess mobility in hospitalized older adults. Regarding functional capacity, half the sample presented loss in functioning between baseline and discharge, while in-hospital mobility evaluated by SPPB can predict loss of function in hospitalized older adults. In addition to in-hospital mobility, dependence for domestic living activities, low levels of cognition and depression improve the detection of cases for being at risk of loss in functional capacity.. Keywords: aged, mobility limitation, hospitalization, validity of testes, reproducibility of tests, functioning.. xi.

(12) Resumo. Introdução A medida que as pessoas envelhecem manter sua funcionalidade permanece um desafio. A funcionalidade consiste da habilidade do indivíduo de realizar atividades de auto-cuidado (e.g. atividades de vida diária – AVD´s) classificados dentro do nível de atividade e participação da Classificação Internacional de Funcionalidade, Incapacidade e Saúde (CIF). Estudos anteriores identificaram fatores de risco para a diminuição da capacidade funcional durante a hospitalização que incluíam idade avançada, características socioeconômicas, incapacidade preexistente, perda cognitiva, delírio, comorbidade. Mobilidade dentro do hospital tem recebido atenção especial devido a sua importante relação com a perda da capacidade funcional. Poucos estudos foram realizados tendo como foco a avaliação dos efeitos da hospitalização em idosos brasileiros. Identificar idosos em risco para a perda funcional durante a hospitalização poderá auxiliar pesquisadores e clínicos a tomar decisões baseadas em evidência. Objetivos Esse estudo contempla três objetivos. Primeiro: promover uma atualização a cerca dos instrumentos relevantes utilizados para avaliar a mobilidade de idosos baseado no conceito da CIF no contexto de hospitalização ou unidades de reabilitação geriátrica intensiva. Segundo: avaliar se a mobilidade avaliada dentro do hospital na admissão é preditiva de perda funcional durante a hospitalização em idosos e identificar fatores preditores de perda funcional. Terceiro: avaliar mudanças funcionais desde antes da internação (medida de base) até a alta hospitalar e identificar preditores de perda funcional. Métodos Esse estudo do tipo coorte prospectivo foi realizado no Hospital Universitário Onofre Lopes (HUOL), localizado em Natal/RN, Brasil entre primeiro de Janeiro de 2014 a 30 de Abril de 2015. Participaram do estudo pacientes com 60 anos ou mais de idade admitidos no hospital e que preencheram os critérios de inclusão: 1) fornecer o termo de consentimento assinado; 2) advindo da comunidade; 3) ser abordado para participar do estudo dentro das primeiras 24 horas de internação. As variáveis independentes incluem características pessoais, atividades de vida doméstica (e.g. atividades instrumentais de vida diária – AIVDs) avaliada pela escala de Lawton e Brody´s, a cognição foi avaliada pelo teste cognitivo de xii.

(13) Leganés, a depressão foi investigada através da escala de depressão geriátrica (GDS-15), a mobilidade dentro do hospital foi avaliada pela Short Physical Performance Battery (SPPB). A variável dependente capacidade funcional foi avaliada pela escala de Katz. Esses instrumentos foram avaliados em dois momentos distintos: na admissão (primeiras 24 horas) e na alta hospitalar (1224 horas antes). A análise estatística inclui análise descritiva, bivariada e multivariada, através de frequências, médias ± erro padrão, receiver-operating characteristic (ROC), regressão logística binária e Equação de Estimativa Generalizada (EEG). Os dados foram inseridos através do SPSS versão 18.0 para Windows. Resultados Na alta hospitalar dos 1256 idosos incluídos na pesquisa 65 (5,1%) foram a óbito durante a hospitalização o que culminou em uma amostra final de 1191 idosos. A idade média foi de 70,02 (±7,34), 684 (57,4%) dos participantes são homens e 790 eram casados (66,3%). A média de dias de internação foi de 7,65 dias (±9,94). Nossa amostra apresentou uma frequência alta para abordagem cirúrgica (>70%). Em relação aos melhores instrumentos para avaliar mobilidade o De Morton Mobility Index (DEMMI) e o SPPB apresentaram o melhor equilíbrio entre a cobertura do conceito de mobilidade,. propriedades. psicométricas. e. aplicabilidade. em. ambiente. hospitalar e unidades de reabilitação geriátrica. O ponto de corte do SPPB de 6.5 (62% sensibilidade, 54% especificidade) identificou 593 (49.8%) pacientes em risco para perda da capacidade funcional. Na regressão logística o SPPB sozinho apresentou predição estatisticamente significante para perda funcional entre admissão e alta hospitalar. Finalmente em relação às mudanças funcionais 52,5% dos idosos receberam alta hospitalar com uma capacidade funcional pior do que antes da internação. Ser dependente para as atividades instrumentais de vida diária, presença de sintomas depressivos, baixos níveis de cognição e mobilidade dentro do hospital foram fatores de risco para perda funcional após um evento de hospitalização. Conclusão Concluímos que DEMMI e SPPB foram os melhores instrumentos para avaliar mobilidade em idosos hospitalizados. Com relação a capacidade funcional metade da amostra apresentou perda da funcionalidade entre linha de base e alta hospitalar e a mobilidade dentro do hospital avaliada pelo SPPB pode predizer perda da capacidade funcional em idosos hospitalizados. Somando à mobilidade dentro do hospital, dependência para atividades domésticas, baixos níveis de xiii.

(14) cognição e depressão melhora a detecção de casos de idosos em risco para perda da capacidade funcional. Palavras-chave: idoso, limitação na mobilidade, hospitalização, validade de testes, confiabilidade, funcionalidade. xiv.

(15) ABBREVIATION LIST ICF – International Classification of Health, Disability and Functioning WHO - World Health Organization ADL - activities of daily living IADL – instrumental activities of daily living HUOL – University Hospital Onofre Lopes SUS - National Health System ICU - Intensive Care Unit GDS-15 - Geriatric Depression Scale SPPB – Short Physical Performance Battery SPSS - Statistical Package for Social Sciences ROC - receiver-operating characteristic AUC - Area under the curve GEE - Generalized Estimating Equation COSMIN - COnsensus-based Standards for the selection of health status Measurement INstruments DEMMI – De Morton Mobility Index ICC - Intraclass Correlation Coefficient SEM - Standard Error of Measurement SDC - Smallest Detectable Change COVS – Clinical outcome Variable Scale FGI – Functional gait index TUG – Timed up and go HABAM – Hierarchic Assessment of Balance and Mobility BFS – Body-fixed sensor SAM – Step activity monitor 6MWT - 6-minute walk xv.

(16) 10Mwt – Ten meter walk test OR - odds ratio CI - confidence interval CAPES – Coordenação de Aperfeiçoamento de Pessoal de Nível Superior. xvi.

(17) FIGURES Introduction Figure 1: Scope of International Classification of Health, Disability and Functioning (ICF). ……………………………………………………………………21. Article 1 Figure 1. Flow diagram of step 1 selection of outcome measures…………..…73. Article 2 Figure 1. Receiver-operator characteristic curve showing sensitivity and 1specificity for loss in ADL ..…………………..……………………………………..88. Article 3 Figure 1. Functional trajectories between pre-admission (baseline) and discharge of hospitalized older adults…………………………………………….109. xvii.

(18) TABLE LIST Article 1 Table 1: Levels of evidence for the overall quality of the measurement properties……………………………………………………………………………...55 Table 2: Characteristics of measurement instruments used to assess mobility in hospitalized older adults……………………………………………………………..56 Table 3: Characteristics of the studies included in the second review for psychometric measures…………………………………………………………….. 61 .... Table 4: Methodological quality of studies reporting on the measurement properties of the 11 instruments…………………………………………………… 66 ….. Table 5: Summary of evidence about the measurement properties of each measurement instrument based on van Tulder et al. (2003)……………………69. Article 2 Table 1: Personal and in-hospital characteristics of the hospitalized older adults (n=1191)……………………………………………………………………………….86 Table 2. Logistic binary regression analyses predicting new ADL loss of functional capacity during hospitalization…………………………………………. 89 .... Article 3 Table 1 - General characteristics of the hospitalized older adults at admission (n=1191)…………………………………………………………………………….. 107 .... Table 2. Predictors of loss in functional capacity from a Generalized Estimating Equation (GEE) regression models……………………………………………….108. xviii.

(19) Summary 1. INTRODUCTION ......................................................................................... 19 1.1 Aging................................................................................................ 19 1.2 Health and Functioning .................................................................. 20 1.3 Functional and mobility capacity during hospitalization and risk factors ............................................................................................................. 23 1.4 Hospital-based context ................................................................... 25 2. OBJECTIVES ............................................................................................. 26 3. HYPOTHESIS ............................................................................................ 27 4. METHODS ................................................................................................. 28 4.1 Study design and data collection .......................................................... 28 4.2 Measures ............................................................................................. 28 4.3 Procedure ............................................................................................. 30 4.4 Analysis................................................................................................. 30 5. RESULTS AND DISCUSSION ..................................................................... 32 5.1 Instruments to evaluate mobility capacity of older adults during hospitalization: A systematic review ................................................................ 33 5.2 Predictive value of Short Physical Performance Battery (SPPB) to detect loss in functional capacity for hospitalized older adults. .................................. 79 5.3 Trajectories and predictors of loss in functional capacity in hospitalized brazilian older adults ........................................................................................ 97 6. CONCLUSION ........................................................................................... 112 7. COMMENTS AND SUGESTIONS ............................................................ 113 8. REFERENCES .......................................................................................... 115 9. APPENDIX ............................................................................................... 117. xix.

(20) 19. 1. INTRODUCTION 1.1. Aging Over the past century, the average human lifespan has doubled. The global share of older adults (aged 60 years or over) increased from 9.2% in 1990 to 11.7% in 2013, and will continue to grow as a proportion of the world population, reaching 21.1% by 2050 (1). By 2047, the number of older adults is projected to exceed the number of children for the first time. The growth of the elderly population is a global phenomenon, and in Brazil changes are taking place in a radical and accelerated way (2). The Brazilian older adult population increased from 3 million in 1960 to 14 million by 2002 (an increase of 500% in just forty years); according to estimates, it will reach 32 million by 2020. Population aging increases health problems, which in turn put pressure on healthcare and social security systems (3). In parallel to the modifications observed in the population, diseases cooccurring with aging have gained greater relevance in society as a whole. In general, diseases in the elderly are chronic and multiple, lasting for several years and requiring constant follow-up, permanent care, continuous medication, and regular examinations and tests. The estimation is that between 75% and 80% of the population over 60 years have at least one chronic disease. In Brazil, more than 11 million older adults are in this condition, and this could increase up to 25 million by 2025 (2). Older adults consume more health services, hospitalizations are more frequent, and hospital bed occupancy time is longer compared to other age brackets. It is unquestionable that one of humankind’s greatest feats has been to extend life expectancy, along with a substantial improvement in the health parameters of populations. Population aging is a natural aspiration for any society, but it is not enough in itself. It is important to live longer, as long as one adds quality to the additional years of life. Thus, the challenge to maintain independent active living with aging emerges (3)..

(21) 20. 1.2. Health, functioning and disability Throughout the years, some models of disability classification have been proposed in an attempt to guide discussions and research about functioning and disability (4). Based on the Saad Nagi model that the World Health Organization (WHO) elaborated during the 1980s, the first classification model was named the International Classification of Impairments, Disabilities and Handicaps (ICIDH). This model proposes a causal model and an unidirectional evolution of disease over time (5). However, this model as well as the model proposed by Nagi was not able to estimate the complex process of disability development. Over the past few years different models have been proposed, but some negative points were observed including a lack of information regarding social and environmental aspects, and a lack of association between classification ratings. Believing that only multidimensional models would be able to estimate the complex process between health, functioning and disability, WHO (5, 6) proposed a new classification in 2001 denominated the International Classification of Health, Disability and Functioning (ICF). The ICF is a classification system which aims to provide a universal classification system of functioning and disability for use in health and health related sectors. The aims of the ICF are: to provide a scientific basis for understanding and studying health and health-related states, outcomes and determinants; to establish a common language for describing health and healthrelated states in order to improve communication between different users; and to permit comparison of data across countries, health care disciplines, services and time and to provide a systematic coding scheme for health information systems. ICF is useful for a broad spectrum of different applications, for example social security, evaluations in managed health care, and population surveys at local, national and international levels. It offers a conceptual framework for information that is applicable to personal health care, including prevention, health promotion, and the improvement of participation by removing or mitigating societal hindrances and encouraging the provision of social supports and facilitators. It is also useful for the study of health care systems in terms of both evaluation and policy formulation (6). ICF encompasses all aspects of human health and some health-relevant components of well-being,.

(22) 21. and describes them in terms of health domains and health-related domains. ICF organizes information into two parts; Part 1 deals with Functioning and Disability, while Part 2 covers Contextual Factors. Each part has two components (figure 1):. 1. Components of Functioning and Disability Body component: comprises two classifications, one for functions of body systems, and one for body structures.. Activities and Participation: component covers the complete range of domains denoting aspects of functioning from both an individual and a societal perspective.. 2. Components of Contextual Factors. Environmental factors: have an impact on all components of functioning and disability and are organized in sequence. Personal Factors: also a component of Contextual Factors but they are not classified in ICF because of the large social and cultural variance associated with them.. Figure 1. Scope of International Classification of Health, Disability and Functioning (ICF).. The components of Functioning and Disability in Part 1 of ICF can be expressed in two components: disability (an indicated problem e.g impairment, activity limitation or participation restriction) and functioning (a non-problematic indication, i.e. neutral aspects of health and health-related states). These components are interpreted by means of four separate but related constructs. Body functions and structures can be interpreted by means of changes in physiological systems or in anatomical structures. Two constructs are available for the Activities and Participation component: performance and capacity (4, 6). The performance qualifier describes what an individual does in his or her current environment, i.e. in the actual context in which they live. The capacity qualifier describes an individual’s ability to execute a task or an action in a “standardized” environment. This construct aims to indicate the highest probable level of functioning that a person may reach in a given domain at a.

(23) 22. given moment. The gap between capacity and performance reflects the difference between the impacts of current and uniform environments, and thus provides a useful guide as to what can be done to the environment of the individual in order to improve performance (6). Although a person's functioning involves a dynamic interaction between health conditions and contextual factors, our approach focuses on health conditions included in the Activities and Participation component. Among the 9 domains of this component (learning and applying knowledge, general tasks and demands, communication, mobility, self-care, domestic life, interpersonal interactions and relationships, major life areas and community, social and civic life), the capacity to perform self-care, domestic life activities and mobility domains fell within the scope of this study (6). The domain of self-care activities (i.e. activities of daily living - ADLs) involves caring for oneself, washing and drying oneself, caring for one's body and body parts, dressing, eating and drinking, and looking after one’s health. Domestic life activities domain (i.e. instrumental activities of daily living - IADLs) includes acquiring a place to live, food, clothing and other necessities, household cleaning and repair, caring for personal and other household objects, and assisting others. The first ones (ADL) are defined as those activities essential for an independent life, while carrying out the IADL is more complex, and requires a higher level of personal autonomy. These IADL scores refer to tasks implying enough capacity as to make decisions, as well as a greater interaction with the environment. Based on these differences, deficits in the IADL normally precede deficits in the ADL (7). Regarding the mobility domain, ICF defines mobility as moving and changing body position or location, or by transferring from one place to another by carrying, moving or manipulating objects, by walking, running or climbing, or by using various forms of transportation (6)..

(24) 23. 1.3. Functional and mobility capacity during hospitalization and risk factors for functional loss A wide array of factors has been identified as contributing to loss in functional capacity in older adults. One of the most significant of these factors is hospitalization (8). The number of hospitalized older adults has been steadily increasing worldwide and constitutes a major population in need of inpatient hospital services (9). Some patients are admitted to the hospital with a diagnosis which does not directly lead to functional loss (e.g. pneumonia, urinary tract infection), yet they demonstrate a general loss in function after a hospital stay, despite adequate medical treatment of the disease. Older adults present reduced functional reserves, rendering them more vulnerable to the effects of hospitalization, which frequently results in failure to recover from the pre-hospitalization functional loss, new loss, or even continued loss (10). Loss in functional capacity is one of the most common negative outcomes of hospitalization, with far-reaching consequences for the patient, family, and health care system (11). In older adults, loss in functional capacity has two stages - an initial loss often occurring before hospitalization, and subsequent failure to maintain or improve function during and after hospitalization. While the initial loss in function is often attributable to the acute illness (12), loss occurred during hospital stay has different reasons (13). Traditional risk factors for functional loss secondary to. hospitalization. are. usually associated. with. age,. sociodemographic. characteristics, comorbidities, severity of illness, malnutrition, cognitive status and depression (14). In-hospital mobility capacity seems to be directly related to functional outcomes (9, 15, 16). The amount of time patients are limited to a bed or chair is an independent predictor of functional loss (17). Some research indicates that 73-83% of the time spent in the hospital by older patients is spent lying in bed (18, 19). Low in-hospital mobility is often related to bed rest orders, limited access to bedside chairs, high beds, and the use of restraints, including intravenous poles and urinary catheters. Immobility and bed rest are associated with adverse outcomes such as high rates of loss of functional capacity and longer hospital stays, especially in older adults (20). Muscle strength decreases rapidly as a result of immobilization. After only ten days of bed rest, a healthy elderly person can lose 12-14% of their muscle.

(25) 24. strength in the lower extremities (21). English et al. (22) demonstrated a clear negative relationship between bed-ridden hospitalized older adults and functional capacity. The consequences usually extend over time, and may produce long-term effects (10). Measures of mobility have been investigated for their predictive value for future incidence of dependence in functional capacity in older adults (17, 23). Unfortunately, many of t h e functional capacity such a s. recognized risk factors for loss in. age, gender,. marital. status,. race,. e d u c a t i o n a n d income a r e n o t directly modifiable. However, in-hospital mobility is one risk factor that could be modifiable by intervention during hospitalization. Identification of patients at high risk of loss in functional capacity is of paramount importance for the prevention of this common negative outcome..

(26) 25. 1.4. Hospital-based context Attention to older adults in the Unified Health System (SUS) (the Brazilian public health care system) is initiated at primary care where promotion and prevention health actions are developed. However, due to changes in the epidemiological profile of this population with high rates of non-communicable diseases, there is an increasing demand for specialized health services (24). The Brazilian public primary health care system is still not prepared to face the change in the demographic profile, which leads to a large number of hospitalizations of older adults (24). Although under certain circumstances hospitalization is the only possible treatment for an older adult patient, it leads to loss of functional capacity, slower and longer recovery, need for high quality human resources and difficulty in continuing care after discharge due to the fact that the majority will need a certain degree of primary care (25). Few studies about the impact of hospitalization and its risk factors have been done in Brazil, and none of them were performed in the Northeast region. Due to the socio-cultural diversity (26), especially in economically less favored regions, the health and functional status of hospitalized Brazilian older adults deserve special attention in order to implement effective strategies for preventing impairments. Thus, in an attempt to fill this gap this study was performed at the Hospital Universitário Onofre Lopes (HUOL),. which is an. academic hospital located in Natal, Rio Grande do Norte. Because of its public service characteristics, the HUOL is 100% integrated into the Unified Health System. The main objective of this hospital is to provide high quality health assistance to the population from Rio Grande do Norte. This 300-bed hospital was chosen as the setting for this research due to its high relevance in the region and its high frequency of admitting older adults. Although hospital environments and processes are not designed to preserve and improve a patient’s functioning, the expectation is when an older adult is hospitalized, his recovery or maintenance of the condition that caused admission should not result in a loss in functional capacity. Therefore, identifying the impact of hospitalization on older adults and identifying risk for loss in functional capacity during hospitalization is crucial and could help researchers and clinicians make informed decisions..

(27) 26. 2. OBJECTIVES 2.1. Principal 2.1.1. Evaluate the impact of hospitalization in functional capacity and mobility of older adults 2.2. Specifics 2.2.1. Article 1: To identify and appraise relevant mobility instruments for hospitalized geriatric patients based on the definition of mobility in the International Classification of Functioning, Disability and Health (ICF) and to appraise and compare their measurement properties. 2.2.2. Article 2: To evaluate if in-hospital mobility assessed at admission is predictive of loss in functional capacity during hospitalization of older adults and verify if others variables combined with in-hospital mobility can better predict loss in functional capacity. 2.2.3. Article 3: To assess functional changes since pre admission until discharge of hospitalized older adults and identify predictors of loss in functional capacity..

(28) 27. 3. HYPOTHESIS 3.1. Article 1: A large number of mobility instruments would be captured by the update review but none of the them will be scored as excellent in all measurement properties. 3.2. Article 2: Short Physical Performance Battery (SPPB) would predict loss of functional capacity during hospitalization taking into consideration personal factors as age, gender, instrumental activities of daily living, cognition, depression, and hospital-related factors such as and surgery. 3.3. Article 3: Older adults will present loss in functional capacity during hospitalization. Age, gender, domestic life activities (IADL), cognition, depression, in-hospital mobility and surgery will be associated to this functional outcome in the Brazilian population..

(29) 28. 4. METHODS 4.1. Study design and data collection A cohort prospective study was conducted at University Hospital Onofre Lopes (HUOL), academic, 300-bed, tertiary care hospital located at Natal, Rio Grande do Norte, Brazil. Data were collected between January 1, 2014 and April 30, 2015. The study enrolled all consecutive patients aged 60 years and older who were acutely admitted and fill the following inclusion criteria: 1) ability to provide informed consent; 2) admitted directly from the community; 3) screening for study eligibility performed in first 24 hours of admission. Patients were excluded if they had any invasive procedure that influenced their functional capacity, were admitted directly to Intensive Care Unit (ICU) or if they were discharged to another hospital or rehabilitation center instead of home. This study was approved by the ethics committee of the hospital (certificate 496.645/2013) (appendix 1) and signed consent was obtained from each participant (appendix 2).. 4.2. Measures Independent and dependent variables were collected by reliable and valuable instruments. 4.2.1 Independent variables include: a). Personal characteristics: included age(years), gender(male/female), marital status (single/ married/divorced), literacy (yes/no), live with (alone/spousal/children/others), caregiver (yes/no), diseases (number of diseases), perceived health (excellent/very good/good/bad/really bad),. admission. service. (cardiology/neurology/urology/gastroenterology/pneumology/others), length of hospital stay(days), perform surgery (no/yes) and death. b). Domestic life activities (IADL activities): evaluated using Lawton and Brody´s eight-item scale that include using the telephone, traveling via car or public transportation, shopping, preparing meals, housecleaning,. handling. money,. doing. laundry. and. taking. medications. Each activity is scored 0 (dependent) or 1 (independent) with global score 0-8 as higher scores mean greater independence.

(30) 29. (12); Test-retest reliability and concurrent validity for older adults present good results (27). c). Cognition: measured by Leganés cognitive test (28) with a global score of 0-32. This scale was developed to be used in older adults with little formal education and its cutoff point is ≤22 (indicative of cognitive impairment); this instrument was choose due HUOL been a public hospital that serves mostly people with low economic income. Psychometric properties from Leganés test for older adults sample showed good results (29).. d). Depression: assessed by the Geriatric Depression Scale (GDS-15). This scale was developed for general older adults, geriatric inpatients and primary care outpatients (30, 31). The scale makes use of a simple response format (yes/no, rated 1or 0) and total score range from 0-15 with a cutoff-point of ≥5 indicating depression (31). GDS15 presents good test-retest reliability (r=.68) and criterion validity (sensitivity 0.80, specificity 0.75) (32).. e). Mobility: evaluated with Short Physical Performance Battery (SPPB). SPPB is easy to administer in both epidemiological and clinical settings and was first developed by Guralnik (33) to be used in community-dwellers. SPPB is a performance-based instrument used to assess mobility that includes usual walking speed over 4m, five chair–stands test, and balance test. The standing balance portion requires participants to maintain, for 10 seconds each, stances with their feet placed side by side, semi-tandem, and in tandem. The scores ranged from 0 to 4 (maximum performance). The 4 meter gait speed measured the time needed to walk 4m at a typical pace. The 5 chair-stands test required participants to rise from a chair with their arms across their chest, five times. A score (0–4) is assigned to performance on time to rise five times from a seated position, standing balance, and 4-m walking velocity. Individuals receive a score of 0 for each task they are unable to complete. Participants score in the “unable to perform” category if they try but are unable or if the interviewer or participant feel it is unsafe. Summing the three individual categorical scores, a summary.

(31) 30. performance score is obtained for each participant (range: 0–12) (34). A score of 12 indicated the highest degree of lower extremity functioning. Standardized instructions were given for each of the three SPPB components, and we used standardized equipment for all patients. For example, all sit-to-stand maneuvers were performed from a chair, without armrests. SPPB has been used as a predictive tool for possible loss of function in older people (35) and has good test-retest reliability (r=.83 95% CI: 0.73, 0.89)(36) and validity (convergent and construct) for community older adults (37).. 4.2.2 Dependent variable is: a) Functional capacity: The Katz scale contains six ADLs activities (bathing, dressing, transferring, toileting, continence and eating) scored as independent (score=1) if able to perform each activity without assistance or dependent (score=0) if not able to performed or if needed assistance(38). Scores range from 0 to 6 points, and higher scores mean greater independence (38, 39). Loss of functional capacity was defined as a loss of at least one point on Katz scale between admission and discharge (39). Test-retest reliability and cross-cultural validity was assessed by Lino et al. (38) and presented good results.. 4.3. Procedure Data were collected by ten research assistants trained in physiotherapy using a standardized interview. After obtaining informed consent from the patient, interview began at older adult´s ward. Data were obtained at two different times: at admission and at discharge. At admission (first 24 hours) all information was obtained during a single session. By the time of admission the older adult also answered questions regarding their functional capacity two weeks before hospitalization (Katz scale). If older adult could not answer at that moment his caregiver was asked to answer questions related to functional capacity of older adult. SPPB test was performed in the hall of the ward. At time of hospital discharge (12-24h before) older adults answered additional questions about their hospitalization (length of stay, surgery) and some.

(32) 31. measures were repeated (Leganes test, GDS-15, SPPB and Katz scale). If a death occurred information regarding it (date, reason) were obtained from the medical chart.. 4.4. Analysis The description of data sample is presented as means ± standard error of the mean for continuous variables and percentage for categorical variables. Data were entered into the Statistical Package for Social Sciences (SPSS) version 18.0 for Windows. Descriptive statistics were used to describe sample characteristics. In article 2 a receiver-operating characteristic (ROC) curve was performed and Area under the curve (AUC) was calculated to determine if SPPB at admission could predict loss of functional capacity during hospitalization. Also a logistic binary regression was used to identify predictors of loss in functional capacity. In article 3 to determine functional trajectories of older adults during hospitalization functional capacity was evaluated in three different times (baseline, admission and discharge). The number of ADL activities that were lost between baseline and discharge, between baseline and admission and between admission and discharge were computed. To identify longitudinal changes in functional capacity since pre admission until discharge a Generalized Estimating Equation (GEE) was performed..

(33) 32. 5. RESULTS AND DISCUSSION Results will be presented according to articles produced.. Article 1 Instruments to evaluate mobility capacity of older adults during hospitalization: A systematic review Karla Vanessa Rodrigues Soares Menezesa*, Claudine Augerb, Weslley Rodrigues de Souza Menezesc, Ricardo Oliveira Guerraa Published: Archives of Gerontology and Geriatrics. 2017. 72: 67-79. Impact factor: 2.086. Qualis CAPES: B1. Article 2 Predictive value of Short Physical Performance Battery (SPPB) to detect loss in functional capacity for hospitalized older adults. Karla Vanessa Rodrigues Soares Menezesa*, Claudine Augerb, Ana Claudia Maurício de Carvalhoa, Ricardo Oliveira Guerraa Submitted to: The Journals of Gerontology. Impact factor: 5.957. Qualis CAPES: A1. Article 3 Trajectories and predictors of loss in functional capacity in hospitalized brazilian older adults Karla Vanessa Rodrigues Soares Menezesa*, Claudine Augerb, Juliana Fernandes de Souza Barbosa, Weslley Rodrigues de Souza Menezesc, Ricardo Oliveira Guerraa Submitted to: Journal of American Geriatric Society (JAGS) Impact factor: 4.388. Qualis CAPES: A1.

(34) 33. ARTICLE 1 Instruments to evaluate mobility capacity of older adults during hospitalization: A systematic review Karla Vanessa Rodrigues Soares Menezesa*, Claudine Augerb, Weslley Rodrigues de Souza Menezesc, Ricardo Oliveira Guerraa Department of Physiotherapy, Federal University of Rio Grande do Norte, Av Sen. Salgado Filho,. a. 3000, Campus Universitário, Natal 59078-970, RN, Brazil Centre de recherche interdisciplinaire en réadaptation du Montréal métropolitain (CRIR), CRIR-. b. CRLB du CIUSSS Centre-Sud-de-l’Ile-de-Montréal |Centre de réadaptation Lucie-Bruneau 2275, avenue Laurier Est Montréal, QC H2H 2N8, Canada c. Department of Physiotherapy, Potiguar University, Av Sen. Salgado Filho 1610, Lagoa Nova, Natal. 59056-000, RN, Brazil ⁎. Corresponding author..

(35) 34.

(36) 35. Abstract Independent mobility is a key factor in predicting morbidity and determining hospital discharge readiness for older patients. The main objective of this study was to identify and appraise relevant mobility instruments for hospitalized geriatric patients based on the definition of mobility in the International Classification of Functioning, Disability and Health (ICF). A systematic review was performed in two consecutive steps. Step 1 identified mobility measurement instruments used to assess patients 60 years of age and over hospitalized in acute care or intensive geriatric rehabilitation units. The aim of the instrument, coverage of mobility construct, applicability (format, training required, administration time and use of assistive devices) were extracted from the literature. For each instrument retained, Step 2 identified and appraised articles reporting their measurement properties. Two independent reviewers used COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN) to critically appraise and compare measurement properties. Step 1 resulted in 6350 articles, 28 of which used 17 different instruments. Step 2 retained 11 instruments with 70 articles reporting their measurement properties in various settings. Three instruments, namely DEMMI, SPPB and Tinetti Scale, had the most extensive and robust measurement properties. DEMMI (judgment-based) and SPPB (performancebased) covered the mobility construct more broadly and both are applicable to hospitalized older adults. Therefore, DEMMI and SPPB present the best balance between mobility coverage, measurement properties and applicability to acute care and intensive geriatric rehabilitation units. To best assess mobility.

(37) 36. in hospitalized older adults, we recommend a combination of judgment- and performance-based measures. Keywords: aged, mobility limitation, hospitalization, validity of testes, reproducibility of tests. 1. Introduction In the World Health Organization’s International Classification of Functioning, Disability and Health (ICF), mobility is defined as “moving by changing body position or location or by transferring from one place to another, by carrying, moving or manipulating objects, by walking, running or climbing, and by using various forms of transportation” (6). Mobility is an important marker and predictor of physical abilities, independence, morbidity, and mortality (40, 41). Mobility is viewed as a dynamic condition that varies even within the same age range. Thus evaluating mobility in older adults is a critical component of assessment. Tinetti (42) suggested that mobility assessment has multiple purposes, including identifying components of mobility difficulty related to performing daily activities, reasons for difficulty with specific tests, and possible health risks caused by immobility. Older adults’ mobility limitation is a marker for risk of adverse outcomes (43). Determining mobility status is an important component of any medical or health assessment for older adults (40). Mobility measures can also (i) help determine whether an individual’s mobility has changed, (ii) identify early signs of decline, and (iii) assist with guiding therapeutic interventions, goal setting, and discharge planning in inpatient programs (40). Restricted mobility and bed rest are common occurrences during acute care. Patients experience a decline.

(38) 37. in mobility from their pre-admission baseline to the second hospital day, with most patients failing to improve by discharge (16, 44, 45). Diminished independence in hospitalized older people is associated with increased risk of transfer to a nursing home, greater care burden and healthcare costs after discharge, as well as higher mortality (46). Although many measurement instruments are currently used to assess mobility in acute care or rehabilitation units, there is a lack of consensus regarding which tool to use during hospitalization. In order to make a rational choice for the use of instruments for mobility assessments in research and practice, it is important to assess and compare their measurement properties (e.g. reliability, validity, responsiveness) with a context-specific approach (e.g. applicability to the context of practice). To our knowledge, only one systematic review (46) evaluated the measurement properties of mobility instruments in the context of acute care or intensive rehabilitation units. Because of highly restrictive criteria, they retained only three instruments (Elderly Mobility Scale, Hierarchical Assessment of Balance and Mobility, and Physical Performance Mobility Examination) and concluded that none had the properties required to accurately measure and monitor mobility of acute care elderly patients. The purpose of this article is to provide an updated review to identify and appraise relevant instruments for the measurement of older adults’ mobility based on the ICF conceptual framework in the context of an acute care or intensive geriatric rehabilitation unit and to appraise and compare their measurement properties..

(39) 38. 2. Methods The review was performed in two consecutive steps. Step 1 identified existing measurement instruments used to assess mobility in acute care or geriatric intensive rehabilitation units. For each instrument retained, Step 2 identified primary research articles reporting their psychometric measurement properties (reliability, validity and responsiveness). Step 2 was not limited to studies involving older adults. 2.1. Step 1 2.1.1. Search strategy For the first search, we mined the following databases: CINAHL, Embase, HaPI, Lilacs, Medline, PsychINFO and Cochrane. Our search strategy included the terms “older adults”, “mobility”, “instrument”, and “hospitalization”. The full search strategy was validated by a librarian and is detailed in Appendices A through D. The reference lists of the articles retained were hand searched to identify additional relevant studies. 2.1.2. Selection criteria A study was selected if it was a primary source article (e.g. not an editorial, review or abstract), published in English, French, Spanish or Portuguese between 2001 and 2015, and involved older inpatients in acute care or intensive rehabilitation units. The format of the instrument had to be self-report, judgmentbased or performance-based, as defined by Arcand and Hébert (47), and it had to be used in a hospital or rehabilitation setting. Self-report instruments are composed of questions answered by the person being evaluated. Judgmentbased instruments use a measurement scale that the evaluator scores based on the subject’s answers or from his/her own observation of behaviors or tasks..

(40) 39. Finally, the performance-based format requires the subject to take one or more standardized tests and generates a ratio score (e.g. duration in seconds, number of steps). For instruments that measured multiple domains (e.g. functional capacity, balance, strength), the report was included if a subtotal score for mobility could be determined. Mobility ranged from bed-bound to independent levels of ambulation according to the activity and participation domains of the International Classification of Functioning, Disability and Health (6). Studies were excluded if the authors did not explicitly address how mobility had been defined and measured, if they used a mobility assessment solely as an inclusion criterion, or if the instrument was disease-specific (e.g. mobility in Parkinson disease, mobility in stroke). The latter criterion was used because a generic measure was considered more applicable for the context of acute care or inpatient rehabilitation.. 2.2. Step 2 2.2.1. Search strategy For each instrument selected, a second search was done in Web of Science and Medline with the terms “reliability”, “validity”, “responsiveness” and “feasibility” and the name of the instrument (see Appendix E). Articles were screened by one reviewer for data about measurement properties based on their titles and abstracts. Full articles of potentially relevant articles were obtained..

(41) 40. 2.2.2. Selection criteria An article was selected if it was published in English, French, Spanish or Portuguese up to 2015 and provided data about the measurement properties for instruments identified in Step 1 that enabled reliability, validity and/or responsiveness to change to be estimated. The same exclusion criteria were applied as in Step 1. 2.2.3. Extraction of conceptual coverage and applicability characteristics To describe the measurement instruments, the aims reported by the authors, number of items, and summary score were extracted. The mobility concept was coded using the ICF to describe the conceptual coverage of each measurement instrument. The ICF provides a framework to code a wide range of information about health and uses a standardized common language for communicating about health and health care. Under the ICF, mobility is classified in domains of “activity and participation” such as Changing and maintaining body position (d410-d429), Carrying, moving and handling objects (d430-d449), Walking and moving (d450-d469), and Moving around using transportation (d470-d489) (6). Every single item of each instrument retained was classified according to an ICF mobility code. Applicability to the clinical context may include information about the burden of assessment and format compatibility (48). Burden of assessment was described in terms of administration time, training needed to use the instrument, and use of assistive devices during testing. Format was classified in three categories: 1) self-report, 2) judgment-based, and 3) performance-based (47)..

(42) 41. 2.2.4. Assessment of methodological quality The methodological quality of the studies was assessed to determine whether the results of the selected studies had methodological strength. Data extraction and assessment of the methodological quality of the studies was performed independently by two reviewers using the COSMIN checklist (49). In case of disagreement between the two reviewers, there was discussion in order to reach consensus. If necessary, a third reviewer made the decision. 2.2.4.1. COSMIN approach The COnsensus-based Standards for the selection of health status Measurement INstruments – COSMIN checklist consists of nine boxes with 518 items concerning methodological standards for how each measurement property should be assessed. Each item is rated on a 4-point scale (poor, fair, good or excellent) and an overall score for the methodological quality of a study is determined for each measurement property separately, by taking the lowest rating of any of the items in a box. The COSMIN checklist can be used to critically appraise the quality of studies concerning a single measurement instrument and to compare measurement instruments. 2.2.4.2. Measurement properties COSMIN divides measurement properties into three domains: reliability, validity. and. responsiveness. (49).. COSMIN. definitions. of. domains,. measurement properties and aspects of measurement properties can be accessed. in. the. COSMIN. checklist. (see. http://www.cosmin.nl).. The. measurement properties include Reliability (internal consistency, inter- and intrarater, test-retest reliability, and measurement error), Validity (content,.

(43) 42. criterion and construct, also subdivided in structural validity, hypothesis testing and cross-cultural validity), and Responsiveness to change.  Reliability Reliability is defined as the extent to which scores for patients who have not changed are the same for repeated measurements under several conditions, e.g. using different sets of items from the same questionnaire (internal consistency); over time (test-retest); by different persons on the same occasion (interrater); or by the same persons on different occasions (intrarater) (49). Reliability encompasses the following measurement properties: 1. Internal consistency: the degree of interrelatedness between items. Represented by Cronbach’s α, factor analysis or Kuder-Richardson Formula 20 (KR-20). 2. Interrater, intrarater and test-retest reliability: represented by the Intraclass Correlation Coefficient (ICC) and Cohen’s Kappa. Kappa is the proportion of the total variance in the measurements which is due to “true” differences between patients. 3. Measurement error: the systematic and random error of patients’ scores that is not attributable to true changes in the construct being measured. It is expressed by the Standard Error of Measurement (SEM) (49). The SEM can be converted into the Smallest Detectable Change (SDC). Changes exceeding the SDC can be labeled as change beyond measurement error.  Validity Validity is the extent to which an instrument measures the construct it purports to measure. It includes:.

(44) 43. 1. Content validity: the degree to which the content of an instrument is an adequate reflection of the construct being measured. Includes also face validity. 2. Criterion validity: the extent to which the scores of an instrument are an adequate reflection of a gold standard. 3. Construct validity: the degree to which the scores of an instrument are consistent with the assumption that the instrument validly measures the construct being measured. Construct validity is further divided into: a. Structural validity: the degree to which the scores of an instrument are an adequate reflection of the dimensionality of the construct being measured. Factor analysis should be performed. b. Hypothesis testing: is an ongoing, iterative process. The more specific the hypotheses are and the more hypotheses are being tested, the more evidence is gathered for construct validity. c. Cross-cultural validity: the degree to which the performance of the items on a translated or culturally adapted instrument is an adequate reflection of the performance of the items of the original version of the instrument.  Responsiveness Responsiveness is the ability of an instrument to detect change over time in the construct being measured. The correlation between change scores of two measurements should be in accordance with predefined hypotheses (50). Although responsiveness is considered to be a separate measurement property from validity, the only difference between construct and criterion validity and.

(45) 44. responsiveness is that validity refers to the validity of a single score, and responsiveness refers to the validity of a change in score (49). 2.2.4.3. Summary of levels of evidence While the COSMIN criteria were used to analyze single studies as described above, we used the classification proposed by the Cochrane Collaboration Back Review Group (see Table 1) to summarize the evidence for the measurement properties of each instrument. The possible overall ratings for a measurement property are “positive”, “indeterminate”, or “negative”, accompanied by levels of evidence. To assess the values for positive, indeterminate or negative, see criteria based on Terwee et al. (51) and Schellingerhout et al. (52). These criteria were originally developed for systematic reviews of clinical trials but, as shown by Schellingerhout et al. (52), they are applicable to reviews of measurement properties of instruments.. 3. Results 3.1. Step 1 review The Step 1 search resulted in a total of 6350 articles. After removing duplicates (n=2520), 3830 articles were screened based on their titles and abstracts. A total of 293 full-text articles were obtained and 265 of them were excluded. From the remaining 28 articles, 17 measurement instruments were identified and underwent an in-depth psychometric evaluation. Figure 1 shows the flow diagram, reasons for exclusion, and the 17 measurement instruments identified in Step 1..

(46) 45. 3.2.. Step 2 review. 3.2.1. Search results After Step 2, 6 of the 17 instruments were excluded (20 Feet Test, Low Mobility Test, 6 Meter Test, Escala Física de Cruz Roja, Physical Performance Test and Lower Limb Summary Performance Score) because we did not find any articles reporting their measurement properties. 3.2.2. Conceptual coverage and applicability characteristics The conceptual coverage and applicability characteristics of the 11 measurement instruments are shown in Table 2. Regarding burden of assessment, administration time varies between 10 seconds and 24 hours, and is shortest for the Timed Up and Go, 6 Minute Walk Test and 10 Meter Walk Test. Five instruments (COVS, DEMMI, FGI, SPPB and Tinetti Scale) require examiner training and need minimal equipment and resources. Equipment includes a pen, chronometer, and standardized chair with or without arms. All instruments allow the use of assistive devices during testing. Regarding the format of the assessment, none of the instruments are self-report, five are judgement-based. and. six. are. performance-based.. Judgement-based. measurement instruments encompass a broad range of mobility tasks defined by the ICF, including changing and maintaining body position, transferring, lifting and carrying objects, fine hand use, walking and moving around. In contrast, except for the TUG and SPPB, all the performance-based instruments are limited to walking (d4500). 3.2.3. Measurement properties A total of 70 articles were found that reported the measurement properties of the 11 selected instruments. The full text of these articles was evaluated,.

(47) 46. which resulted in the exclusion of 23 articles (2 focused on balance validity not mobility as defined by the ICF, 8 examined pulmonary capacity not mobility, 8 did not report measurement properties, and 5 involved a full text in languages not included). Table 3 details the general characteristics of the 47 eligible articles, 68% (n=32) of which evaluated non-hospitalized subjects, 27.7% (n=13) evaluated hospitalized subjects, and 4.3% (n=2) evaluated a mix of hospitalized and non-hospitalized subjects. Table 4 presents their measurement properties based on COSMIN criteria, and Table 5 summarizes the evidence for the measurement properties of each measurement instrument.. 4. Discussion Our main goal was to identify and appraise relevant instruments for the measurement of the mobility capacity of older adults hospitalized in acute care or rehabilitation units. This review identified 11 mobility instruments. In a previous review of instruments used to assess mobility in acute care, de Morton et al. (46) identified three instruments (HABAM (53), Elderly Mobility Scale (54) and Physical Performance Mobility Examination (55)) and classified them all as poor quality. However, they did not use a standardized approach to assess the tools’ measurement properties. Moreover, their inclusion criteria (takes less than 10 minutes to administer, does not require minimum level of experience to administer, consists of more than one item to assess mobility) led to the exclusion of most instruments. For example, instruments like BFS, SAM, 6 Minute Walk Test and 10 Meter Walk Test were excluded because they consisted of a single item (walking). From this perspective, our review is the most comprehensive review of mobility instruments for hospitalized older adults..

(48) 47. To achieve this, and according to the ICF mobility concept, we first retained any instrument used to assess mobility in hospitalized older adults without considering their psychometric properties. To evaluate the quality of these instruments, we then used a reliable and valid approach to assess all the instruments in a standardized way. Regarding the conceptual coverage of the mobility construct, a majority of items assessed by the 11 selected measurement instruments were coded by the ICF as d4500 (walking short distances). In fact, four instruments evaluated only this aspect of mobility. The remaining instruments evaluated between two and seven aspects of mobility. Besides walking, instruments that have greater coverage of mobility include changes in mobility across a broad spectrum of abilities including bed mobility, maintaining and changing position, chair transfers, upper extremity mobility and moving around. This variety in coverage gives clinicians and researchers multiple options. If it is important to evaluate the full spectrum from bed mobility to climbing stairs, instruments like COVS and DEMMI would be a better choice. If, on the other hand, the goal is a straightforward and quick measure, an instrument that measures only one item of mobility (e.g. walking) like BFS, SAM or 6 Minute Walk Test would present a good response. Increasingly, standardized tests of physical performance are being applied in research and geriatric assessment (33). Performance-based instruments have been found to be strongly associated with multiple measures of health status, are more sensitive to change than self-report instruments, and might be more useful in longitudinal evaluations (33). Time of administration is another crucial factor when evaluating hospitalized patients, and eight instruments took.

(49) 48. less than 15 minutes to administer. These instruments are practical and may be a good fit for use in a hospital ward. However, one limitation of these instruments, especially DEMMI and SPPB, is that for specific populations some of the items (pick up a pen from the floor, sit/stand or jump) may not be appropriate at admission to a hospital or rehabilitation unit (1). Regarding the need for training, we observed that five instruments required training. This may reduce bias and lead to greater standardization of results. Another resemblance between those instruments is that they do not need a lot of material to evaluate mobility, although some instruments like SPPB and Tinetti Scale require a specific chair. Sometimes in a hospital setting, finding a standardized chair with certain specifications like height, with or without arms, could be a problem and a non-standardized chair may influence the ability to transfer from sit to stand. Auger et al. (56) also mentioned this problem and suggested further studies to investigate the impact of floor covering, armrests and chair heights to provide norms that could be used in different contexts. Methodological quality criteria are crucial for assessment and to identify efficient instruments for clinical practice (50). The COSMIN criteria facilitated a separate judgment concerning the methodological quality of the selected studies and their results. In our review, SPPB and Tinetti Scale had good to excellent intrarater and interrater reliability. Although instruments like COVS, DEMMI and TUG showed positive results for reliability (ICC>0.80), they shared similar methodological problems. The most frequent was the small sample size, which led to fair or poor results for measurement properties. The COSMIN scoring system was initially developed to assess psychometric properties in self-report questionnaires and defines a minimum acceptable sample size as 30.

(50) 49. (fair) and acceptable sample size as 100 (excellent). Dobson et al. (57) anticipated this problem and used modified COSMIN criteria. They used the total sample size of eligible combined studies in what they called “second worst score counts”. Evidence was labelled “strong” when the total sample size of eligible combined studies was ≥100, “moderate” with total samples between 50 and 99, “limited” with total samples between 25 and 49, and “unknown” with samples less than 25. In this way, the authors avoided excluding many small studies. In our study we followed the original COSMIN criteria; reliability was low for 73% of our sample, and 3 tools met the highest reliability standards (SPPB, Tinetti Scale and 6 Minute Walk Test). Our review found substantial gaps in validity for most of the measurement instruments. None of them were evaluated for content validity, and structural validity was missing in most of the instruments with multiple dimensions. It was difficult to determine the content coverage of the instruments because none of the studies examined the constructs of the instruments. This problem may be because mobility is a variable for which content is considered implicit. Evaluating content validity would ensure that the instrument adequately covers the domain under investigation (58). Four instruments presented multiple dimensions but only FGI reported structural validity. Structural or construct validity refers to how well a measurement instrument can measure the theoretical concept being investigated and to the number of dimensions the score can explain. Assessment of structural validity involves factor analysis and aims to identify the potential structure of the scale and reduce the number of items (59). More studies regarding the structural validity of the instruments presented in this review would allow researchers to choose an instrument.

(51) 50. capable of covering the mobility concept and evaluating subjects more precisely. Criterion validity was evaluated for most of the measurement instruments. COVS, DEMMI, FGI and SPPB presented excellent criterion validity (37, 59-63). FGI is a good instrument to measure mobility and has good predictive validity for falls. It has a 84% chance of making a correct prediction for falls using a cutoff point of 18 for inpatients. It is very important to predict patients who are at increased risk for falling so that the clinical team can be alerted to that risk and provide appropriate interventions to avoid potentially serious adverse outcomes (59). SPPB predicts mortality and functional decline in older adults discharged from acute care hospital (64). Factors associated with decline in SPPB summary scores over time can be an early warning system to identify individuals at greater risk for subsequent decline in essential lower body functioning. Regarding SPPB scores, interventions can increase falls efficacy and improve outcomes in people recently discharged from hospital (65). Therefore, choosing an instrument capable of predicting functional decline, falls, or other negative outcomes during a hospital stay and in the first few weeks after discharge can provide additional information on future health risks in older acutely ill patients. This may also support and encourage the systematic assessment of these objective tests in everyday clinical practice (66). Finally, the last measurement property evaluated was responsiveness. DEMMI, FGI and SPPB showed excellent responsiveness. According to Vogelzang (58), responsiveness is the ability of an instrument to measure a meaningful or clinically significant change in a clinical state. Responsiveness is a very important characteristic of a tool since it makes it possible to detect.