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Keywords:

  • Functional mobility;
  • quality of life;
  • elderly;
  • rehabilitation

Abstract

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusion
  7. Acknowledgments
  8. References

Purpose

The purpose of this study was to assess the long-term functional status and quality of life of older individuals with functional mobility impairment.

Design

A prospective longitudinal study was conducted.

Methods

The study sample consisted of elderly patients who had been admitted to a rehabilitation facility in Hamburg, Germany. Data were collected from February 2008 to August 2009 in the rehabilitation center and the living environment of the participants after discharge. Quality of life was assessed using the WHO Quality of Life-BREF; activities of daily living were measured using the Barthel-Index (BI).

Findings

Functional status and overall quality of life increased from admission (BI = 73.33) to 6 months postadmission (BI = 89.29) but decreased at 12 months postadmission (BI = 85.71). Quality of life significantly increased in the psychological domain from admission (57.85) to 6 months follow-up (67.85) (p = .010). Men showed a better functional status over time (p = .010) than women. Higher quality of life scores were associated with higher MMSE (p = .031) and self-efficacy scores (p = .019) at admission.

Conclusion

The findings of this study suggest a need for interventions to improve functional status and quality of life in this population, especially following 6 months after discharge.

Clinical Relevance

Special interventions should address physical quality of life and physical functioning. Gender differences should be considered in planning and implementing programs.

The maintenance of functional mobility, with regard to the fundamental functions of daily living, is a relevant resource for the maintenance of independence, autonomy, and quality of life in older individuals (Mollenkopf & Flaschenträger, 2001). The loss of functional status is a major risk factor of disability and/or nursing care dependency, and thus for admittance to a long-term nursing home (Brunnett, Hasseler, Strupeit, & Deneke, 2009). The multimorbid elderly are particularly at risk of functional impairments because acute conditions associated with impairments of the musculoskeletal system such as stroke or hip fractures most commonly occur in this population (Günster, 2011; Tinetti, Speechley, & Ginter, 1988). Required clinical rehabilitation can have positive effects on the functional status and quality of life of those affected (Saxena, Ng, Koh, Yong, & Fong, 2007; Shyu, Maa, Chen, & Chen, 2009). However, research into the functional status and quality of life after rehabilitation shows different results. Most of the research that focuses on the long-term effects of functional mobility impairments after discharge from rehabilitation has been conducted on stroke survivors. Several studies have focused on functional status as a main outcome. Functional status in stroke survivors over time has been reported as (relatively) good (Shen et al., 2011) or improved (compared with time at admission; (Saxena et al., 2007) at 6 months of follow-up). Other studies have indicated a partial decrease in functional status 13 months after discharge, but stable or increased functional status in some stroke survivors (Wagle et al., 2011). These results may indicate a decrease in functional status after a longer period postdischarge. Depression (Saxena et al., 2007), discharge positive emotion (Ostir, Berges, Ottenbacher, Clow, & Ottenbacher, 2008), cognitive function (Saxena et al., 2007; Wagle et al., 2011), old age, gender (Appelros, Stegmayr, & Terent, 2010; Lai, Duncan, Dew, & Keighley, 2005), and malnutrition (Shen et al., 2011) have been associated with physical functioning.

Other studies have focused on quality of life as a main outcome (Patel et al., 2006). At a 7-year follow-up, quality of life was measured as either poor or relatively good (Leach, Gall, Dewey, Macdonell, & Thrift, 2011). The results from studies with up to 12 months of follow-up have been heterogeneous. Some results have indicated severe distress (Horgan, O'Regan, Cunningham, & Finn, 2009), poor quality of life (Patel et al., 2006), or a partial decrease in quality of life domains (Kwok et al., 2006; Lalu, 2003; Pan, Song, Lee, & Kwok, 2008). Other results have shown a continuous improvement of most quality of life domains 12 months after discharge (Shyu et al., 2009). At 6 months of follow-up, quality of life has been reported as having declined since discharge (Hopman & Verner, 2003). Summarizing these findings, quality of life appears to decrease after a longer period from discharge in most cases. However, results are heterogeneous but may not be comparable overall because different methods have been used. Factors that have been associated with long-term quality of life include activities of daily living (Kwok et al., 2006; Leach et al., 2011; Shyu et al., 2009), handicap (Leach et al., 2011; Patel et al., 2006), depression (Kwok et al., 2006; Pan et al., 2008), severity of stroke (Gosman-Hedstrom, Claesson, & Blomstrand, 2008), disability (Patel et al., 2006), and gender (Gargano & Reeves, 2007).

In summary, evidence regarding long-term effects on functional status and quality of life in older individuals with functional mobility impairments remains unclear. Moreover, little is known on this topic from studies in the German healthcare setting (Lalu, 2003). Thus, there is a need for knowledge concerning long-term effects in older individuals with functional impairment, especially in the German healthcare setting. Due to the demographic changes in Germany, the significance of functional status promotion will increase; life expectancy and the number of older individuals will increase, and thus, more individuals will be at risk of functional impairment in the future.

To target useful programs and measures, healthcare professionals should be aware of the long-term outcomes and predictors.

The aim of this study was to assess quality of life and functional status in elderly individuals with functional mobility impairment that had been admitted to an aged care rehabilitation facility at admission, 6 months, and 12 months. Another aim was to evaluate if gender or age are associated with functional status and if gender, age, cognitive status, educational level, self-efficacy, or functional status are associated with quality of life.

Methods

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusion
  7. Acknowledgments
  8. References

Design

A prospective longitudinal design was used with three measurements. The measurements took place at admission in the geriatric-clinical setting (t1) and 6 months (t2) and 12 months (t3) postadmission in the living arrangement of the participant.

Ethical approval

The study protocol was approved by the Ethics Commission of the Medical Association of Hamburg (PV2972).

Setting

The study was single-sited and conducted in a hospital with a geriatric focus in Hamburg and after discharge, in the living environment of participants living in the greater area of Hamburg.

Sample

The study sample was composed of patients who had been admitted to the hospital. The inclusion criteria were as follows: a pre-existing diagnosis of functional mobility impairment of the musculoskeletal system or stroke (ICD-10: S00–T98 [except T36–87], T89, T88, T90–T95, T98, M00–M99, I61, I63, I66), older than 60 years, not lacking spatial or temporal orientation, not having functional and cognitive impairments, able to communicate and speak German, living in greater Hamburg (home or nursing home), and providing informed written consent. The exclusion criteria were as follows: having a score lower than 25 points according to the Mini Mental State Examination (MMSE), suffering from a disease supposedly leading to death during the period under study, and being discharged within the first week after admission.

Outcome measures

The primary outcome measures of this study were quality of life and functional mobility. Quality of life was assessed using the World Health Organization Quality of Life-BREF (WHOQOL-BREF). This questionnaire is a well-evaluated, short version of the WHOQOL-100 questionnaire for health quality of life (Angermeyer, Kilian, & Matschinger, 2000). Functional status was measured using the Barthel Index (BI). The BI is a standard geriatric assessment instrument for assessing fundamental functions of daily living (Nikolaus, Bach, Oster, & Schlierf, 1996).

The independent variables were demographic characteristics, cognitive impairment, and self-efficacy. Cognitive impairment was assessed using the MMSE, and self-efficacy was assessed using a 10-item psychometric scale, the General Self-Efficacy Scale.

Data were collected by two study nurses who were supervised by two research associates. The same two study nurses conducted the assessment by using questionnaires and interviews.

Statistical analysis

Descriptive statistics were used to describe the basic characteristics of all participants. Correlations between the metric/ordinal variables were examined by Pearson's and Spearman's correlations. Chi-square tests, Fisher's exact tests, and t-tests were used to analyze the data. For the longitudinal analyses, we only used measurements of participants with complete data for each instrument at t1, t2, and t3. We used fixed-effects models of analysis of variance for repeated measurements (generalized linear models, GLM) to analyze longitudinal effects for our main outcome parameters. We generally adjusted these models for confounding factors, such as gender and age at admission. Regarding self-efficacy status, we adjusted for cognitive impairment (MMSE) and educational level. Regarding quality of life, we adjusted the models for confounding factors, such as gender, age, cognitive impairment (MMSE), self-efficacy, functional status, and educational level at admission. Interactions between confounding variables were not modeled because of the small number of study participants. Statistical model assumptions of normal distribution and multicollinearity for variables were examined before conducting further analyses. Significance was set at p < .05. We considered values of p < .10 as trending toward significance. All statistical analyses were carried out using IBM SPSS Statistics for Windows, version 19.0 (IBM Corp., Armonk, NY).

Results

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusion
  7. Acknowledgments
  8. References

Participants

A sample of 202 patients met the inclusion criteria, 85 of which provided consent to participate in the study and completed the baseline assessment. After 6 months, 23 participants were lost to follow-up, and after 12 months, another 15 patients were unable to finish the study (see Figure 1). Table 1 shows the sociodemographic characteristics of the study sample.

Table 1. Sociodemographic characteristics
Mean age, years (SD)83.44 (8.71)
Gender,% (n)
Male32.9
Female67.1
Birthplace,%
Germany92.6
Other7.4
Family status%
Married35.8
Single9.9
Divorced7.4
Widowed46.9
Education,%
Secondary school level I (until 10th grade)75.3
Secondary school level II (after 10th grade)24.7
Professional education (Berufsabschluss),%
Vocational training61.7
University degree14.8
No professional education23.5
image

Figure 1. Drop out analysis

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Functional status

The mean BI score of all participants was 73.33 (SD 17.96) at baseline (admission), indicating moderate disability. At 6 months of follow-up, the mean BI score was higher, at a score of 89.29 (SD 14.54), which again indicates moderate disability (see Table 2). After 12 months of follow-up, the mean BI score was slightly lower, with a score of 85.71 (SD 16.32) (moderate disability). Functional abilities over time showed no significant trend (GLM [Wilks-Lambda]; p = .466). Interactions between age and development over time were not observed (GLM [Wilks-Lambda]; p = .604), but the statistical analysis revealed interactions between gender and development over time (GLM [Wilks-Lambda]; p = .010). Male participants showed an increase over time, whereas female participants did not show a continuous trend over time. No group differences were observed (GLM; p > .005) (see Table 3).

Table 2. Descriptive statistics
 t1 (Admission)t2 (6 Months of Follow-up)t3 (12 Months of Follow-up)
MaleFemaleAllMaleFemaleAllMaleFemaleAll
  1. Values denote mean (SD).

Barthel index80.00 (19.54)70.76 (16.90)73.33 (17.96)86.25 (21.01)90.50 (11.24)89.29 (14.54)87.92 (14.94)84.83 (16.93)85.71 (16.32)
WHOQOL-BREF
Overall48.21 (26.44)41.66 (23.87)43.50 (24.23)66.07 (28.60)58.33 (12.86)60.50 (18.28)57.14 (25.87)52.78 (10.98)54.00 (16.02)
Physical52.12 (24.63)39.84 (17.42)43.15 (19.87)72.53 (18.51)65.41 (13.22)67.33 (14.78)63.52 (18.95)55.13 (15.34)57.39 (16.43)
Psychological64.28 (21.08)55.48 (22.31)57.85 (21.93)63.09 (25.16)69.60 (15.30)67.85 (18.14)68.57 (13.64)65.21 (13.79)66.12 (13.56)
Social71.42 (15.10)67.36 (21.82)68.50 (19.94)66.07 (28.70)69.21 (18.25)68.33 (21.07)73.21 (18.29)72.68 (14.51)72.83 (15.26)
Environment70.98 (14.84)60.69 (16.54)63.46 (16.48)83.48 (15.49)71.87 (13.97)75.00 (15.02)75.57 (16.63)74.48 (13.99)74.77 (14.40)
Table 3. Results from GLM-analyses for main outcome parameters
 Effect Over Time (Multivariate Test on Within-Subjects Effects)Interaction of Time and Factor (Multivariate Test on Within-Subjects Effects)Group Differences (Test on Between-Subjects Effects)
  1. MMSE, Mini Mental State Examination.

  2. a

    Wilks-Lambda.

  3. b

    Greenhouse-Geisser.

  4. c

    p < .05.

Functional status (Barthel Index)p = .466a

Gender p = .0101c

Age p = .604a

Gender p = .624

Age p = .992

Quality of life – WHOQOL-BREF
Overallp = .064a

Gender p = .175a

Age p = .154a

MMSE p = .031a,c

Educational level p = .180a

Self-efficacy p = .019a,c

Functional status p = .691a

Gender p = .087

Age p = .078

MMSE p = .105

Educational level p = .522

Self-efficacy p = .117

Functional status p = .758

Physicalp = .776a

Gender p = .936a

Age p = .914a

MMSE p = .178a

Educational level p = .919a

Self-efficacy p = .481a

Functional status p = .142a

Gender p = .303

Age p = .049c

MMSE p = .627

Educational level p = .214

Self-efficacy p = .051

Functional status p = .575

Psychologicalp = .010a

Gender p = .273a

Age p = .222a

MMSE p = .005a,c

Educational level p = .245a

Self-efficacy p = .267a

Functional status p = .095a

Gender p = .464

Age p = .355

MMSE p = .051

Educational level p = .332

Self-efficacy p = .002c

Functional status p = .639

Socialp = .185a

Gender p = .629a

Age p = .277a

MMSE p = .854a

Educational level p = .043a,c

Self-efficacy p = .321a

Functional status p = .296a

Gender p = .289

Age p = .149

MMSE p = .363

Educational level p = .531

Self-efficacy p = .089

Functional status p = .011c

Environmentp = .386b

Gender p = .172b

Age p = .794b

MMSE p = .132b

Educational level p = 0.585b

Self-efficacy p = .592b

Functional status p = .600b

Gender p = .321

Age p = .123

MMSE p = .376

Educational level p = .599

Self-efficacy p = .038c

Functional status p = .104

Quality of life

Overall

The mean overall WHOQOL-BREF score of all participants was 43.50 (SD 24.23) at baseline, 60.50 (SD 18.28) at 6 months of follow-up, and 54.00 (SD 16.02) at 12 months of follow-up (see Table 2). Statistical analyses showed a trend toward a significant increase in the mean overall WHOQOL-BREF score (GLM [Wilks-Lambda]; p = .064). No interactions between gender, age, educational level, and functional status and development over time were observed (GLM [Greenhouse-Geisser]; p > .050). We observed a minor interaction between the self-efficacy score and cognitive impairment (MMSE) score with time (GLM [Wilks-Lambda]; p = .019/p = .031), showing a decreasing influence on the mean overall WHOQOL-BREF score over time. Minor group differences were only observed for age (GLM; p = .078) and gender (GLM; p = .087). Older participants and male participants showed higher overall quality of life on average (see Table 3).

Physical

The mean physical quality of life score of all participants was 43.15 (SD 19.87) at admission, 67.33 (SD 14.78) at 6 months of follow-up, and 57.39 (SD 16.43) at 12 months of follow-up (see Table 2). Statistical analyses showed no significant increase in the mean physical WHOQOL-BREF score (GLM [Wilks-Lambda]; p = .776). Interactions between gender, age, MMSE, educational level, self-efficacy, and functional status and development over time were not observed (GLM [Greenhouse-Geisser]; p > .050). Group differences were only observed for age (GLM; p = .049) and self-efficacy by trend (GLM; p = .051). Older participants showed lower physical quality of life on average, but a higher self-efficacy score resulted in a higher physical quality of life on average (see Table 3).

Psychological

The mean score of psychological quality of life of all participants at baseline was 57.85 (21.93). After 6 months, the psychological quality of life score increased to 67.85 (SD 18.14) and maintained constant after 12 months, with a score of 66.12 (SD 13.56) (see Table 2). Statistical analyses showed a significant influence of time on the mean psychological WHOQOL-BREF score (GLM [Wilks-Lambda]; p = .010). Including possible confounding factors, psychological quality of life increased during the first 6 months of follow-up but subsequently decreased again. Interactions between gender, age, educational level, and self-efficacy and development over time were not observed (GLM [Greenhouse-Geisser]; p > .050). For cognitive impairment (MMSE), the mean psychological WHOQOL-BREF score decreased over time (GLM [Wilks-Lambda]; p = .005). For the functional status, the mean psychological WHOQOL-BREF score decreased over time (GLM [Wilks-Lambda]; p = .095). Group differences were only observed for self-efficacy (GLM; p = .002) and MMSE by trend (GLM; p = .051). Participants with a higher self-efficacy score showed a higher psychological quality of life on average, and participants with better cognitive functioning showed lower psychological quality of life on average (see Table 3).

Social

The mean social quality of life score in all participants was 68.50 (SD 19.94) at admission, 68.33 (SD 21.07) at 6 months of follow-up, and 72.83 (SD 15.26) at 12 months of follow-up (see Table 2), indicating an increase in social quality of life between 6 and 12 months of follow-up. The statistical analyses showed no significant increase in the mean social WHOQOL-BREF score (GLM [Wilks-Lambda]; p = .185). Interactions between gender, age, MMSE, self-efficacy, and functional status and development over time were not observed (GLM [Greenhouse-Geisser]; p > .050). For the educational level, we observed an increase in quality of life over time for participants with a higher educational level (GLM [Wilks-Lambda]; p = .043). Group differences were only observed for functional status (GLM; p = .011) and self-efficacy by trend (GLM; p = .089). Higher functional status and a higher self-efficacy score resulted in higher social quality of life on average (see Table 3).

Environment

The mean score of environmental quality of life for all participants at baseline was 63.46 (SD 16.48). After 6 months (75.00; SD 15.02) and 12 months (74.77; SD 14.40), the environmental quality of life score increased (see Table 2). The statistical analyses showed no significant increase in the mean environmental WHOQOL-BREF score (GLM [Greenhouse-Geisser]; p = .386). Interactions between gender, age, MMSE, educational level, self-efficacy, and functional status and development over time were not observed (GLM [Greenhouse-Geisser]; p > .050). Group differences were only observed for self-efficacy (GLM; p = .038). A higher self-efficacy score resulted in a higher quality of life on average (see Table 3).

Discussion

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusion
  7. Acknowledgments
  8. References

This study aimed to assess quality of life and functional status in older individuals with functional mobility impairment that had been admitted to an aged care rehabilitation facility at admission, 6 months, and 12 months. Another aim was to evaluate if gender or age is associated with functional status and if gender, age, cognitive status, educational level, self-efficacy, or functional status are associated with quality of life.

Functional status

The results of this study showed no statistically significant increase in functional status from admission to 6 months and 12 months of follow-up. Functional status was at a moderate level at all measures of time, with higher scores at 6 and 12 months of follow-up and the highest score at 6 months of follow-up. These results are partially similar to other studies reporting increases in functional status in some of the studied participants (Saxena et al., 2007; Shen et al., 2011; Wagle et al., 2011); however, functional status was not significantly increased in the present study. Other studies have indicated a considerable improvement in functional status (Saxena et al., 2007). This result may be because in several studies, baseline data were measured at discharge, and participants already benefited from rehabilitation, which may have led to a relatively high functional status score that was not significantly different from follow-up scores. In this study, BI score slightly decreased from 6 months to 12 months follow-up, which may suggest a proceeding decline over a longer period of time. Gender was associated with functional status over time. The functional status of men significantly increased over time, whereas that of women did not show a continuous trend over time. This finding has been previously reported in other studies (Appelros et al., 2010; Fukuda, Kanda, Kamide, Akutsu, & Sakai, 2009; Gargano & Reeves, 2007; Lai et al., 2005).

The findings of this study indicate that the functional status after discharge from rehabilitation appears to be moderate, with a better functional status after 6 and 12 months; however, no significant differences were observed over time. Nevertheless, attention must be paid to activities of daily living (ADL) outcomes after a longer period of time. The results suggest a decrease in functional status between 6 and 12 months after discharge. Hence, after-discharge care should be focused on functional status issues, particularly after the first 6 months and even longer periods.

Key Practice Points
  • The present study aimed to determine the long-term outcomes postrehabilitation in elderly individuals with functional mobility impairments.
  • Both functional status and quality of life increased after 6 months but decreased from 6 to 12 months of follow-up.
  • There is a need for interventions to improve functional mobility and quality of life following 6 months after discharge.
  • By knowing these outcomes, professionals can guide interventions to obtain and facilitate functional mobility.

Quality of life

The overall quality of life increased from admission to 6 months of follow-up but decreased from 6 months to 12 months of follow-up; however, these differences were not statistically significant. Quality of life in the psychological domain increased significantly from admission to 6 months and 12 months follow-up. These results are partially in line with previous findings from a study in older stroke patients after discharge from the hospital (Shyu et al., 2009). However, in this study, no significant improvements were observed over time. Apart from this observation, these findings contrast with results from other studies (Hopman & Verner, 2003; Horgan et al., 2009; Patel et al., 2006).

To interpret the WHOQOL-BREF scores, it is helpful to compare scores with the standard scores of the general population (Angermeyer et al., 2000). The mean age of study participants was 83.44 (SD 8.71). The overall standard score of Germans between 76 and 85 years is 58.5. The standard domain scores in this population are 60.2 (physical), 65.7 (psychological), 64.4 (social), and 67.3 (environment). The overall score of the study sample was considerably lower than standard at baseline, increased to an above average score after 6 months, and decreased back to a substandard score after 12 months. Notably, quality of life improvement and impairment depends on the domain. The physical domain score was considerably above average after 6 months but then decreased rapidly below standard after 12 months. These findings are similar to the results of Shyu et al. (2009), who found that physical quality of life in older long-term stroke survivors was lower than average. In contrast, psychological and environment domain scores were considerably above average at both times of follow-ups. The social domain score even increased over time and stayed above average at all times.

Considering these results, it becomes clear that quality of life postdischarge is below average in a physiological manner only. Psychological, social, and environmental quality of life appears to be at an average level. It is not surprising that individuals suffering from physical impairments, such as stroke survivors and patients with fracture-related impairments, have a low physical quality of life. Rehabilitation provided after a stroke or fractures should be focused especially on physical functioning. It appears impossible to entirely regain physical functioning in most of the cases, especially in stroke survivors. However, even small improvements may increase quality of life in these individuals. Additionally, professional nursing care and nursing consulting should deliver effective interventions for older individuals with functional mobility impairments and focus particularly on physical quality of life aspects because a decrease in the physical quality of life occurs after 6 months from discharge and longer. Overall, quality of life at admission was associated with MMSE and self-efficacy scores, suggesting a positive effect of cognitive status on quality of life. This association suggests that cognition status becomes important in the acute phase. After rehabilitation, quality of life may be less important. However, the cognitive status of the participant was related to their self-efficacy at admission, suggesting that patients who saw themselves as able to cope with the situation reached an average quality of life. Nevertheless, self-efficacy had no effect on quality of life after discharge.

Limitations

Several limitations should be considered. Patients who had functional and cognitive impairments were not able to communicate and/or did not speak German, lacking spatial or temporal orientation and critically ill patients were excluded and the study sample was restricted to one site and a rural area. This may have led to an unintended selection bias for participants. Therefore, the generalizability of the study results is limited. Moreover, the findings of this study should be considered with regard to the relatively small sample size. This small size may have influenced the precision of the results, increasing the probability of a type II error.

Conclusion

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusion
  7. Acknowledgments
  8. References

The results of this study suggest a need for special nursing care interventions for older individuals with functional mobility impairments after discharge from a rehabilitation facility, especially after a period of 6 months. Interventions should include measures to improve or address skills in ADL and to improve the physical aspects of quality of life issues. To address this task, it may be beneficial to focus on special prevention programs, including consulting in functional mobility, e.g., home visits. Furthermore, professionals in nursing care should be aware of gender differences in developing and conducting interventions addressing physical functioning. Additional research in this section should focus on studies evaluating the development of functional status and quality of life with follow-up beyond 12 months.

Acknowledgments

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusion
  7. Acknowledgments
  8. References

The study is funded by the German Federal Ministry of Education and Science (BMBF) (grant number 01ET0712) – network spokesman Prof. Dr. Wolfgang von Renteln Kruse.

References

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusion
  7. Acknowledgments
  8. References