• aging;
  • evidence-based nursing;
  • hospital;
  • ISAR-HP;
  • prevention of functional decline.


  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. References

This paper presents a discussion of knowledge and awareness regarding prevention of functional decline in older hospitalized patients.

Functional decline is experienced by 30–60% of the older hospitalized patients, resulting in decreased independence and other adverse health outcomes.

One literature study and four cohort studies (total n = 1628) were conducted to develop and validate an instrument to identify older hospitalized patients at risk for functional decline. An evidence-based best practice was developed to improve the quality of care for older patients.

This paper shows the relevance and the complexity of this problem and shows that patients at risk can be recognized by four simple questions.

Due to their ability to observe and guide patients and their 24-h patient supervision, nurses should play a key role in strategies to prevent functional decline. Nurses should assess the geriatric needs in patients at risk and based on these initiate and coordinate multi-professional interventions. Given the growing number of older people in western society and the growing need for care, action to prevent functional decline cannot be withheld. Knowledge of the ageing process, implementation of an evidence-based programme and a multidisciplinary approach is a basic ingredient to prevent functional decline.


  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. References

Mrs. Smit (79 years old) was admitted to the hospital with pneumonia. Using the ISAR-HP, she was identified as a patient at risk for functional decline. A comprehensive geriatric assessment was applied: a urinary tract infection was diagnosed causing incontinence and delirium, she showed malnutrition and was at high risk for falls as she showed mobility and visual problems. She was treated for the medical problems (pneumonia, urinary tract infection and delirium), she and her family were informed about the nature of the problems, measures were installed to prevent falling and she received extra food supplies. Before discharge, she was informed about the importance of good visual capacity and fall prevention actions and referred to an optometrist. When the time came to return home everything was organized, together with the family. She could stay independent in her home and did not decline in functional status.


  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. References

Hospitalization is a risky event for older people, as 30–60% suffers a functional decline related to hospital admission resulting in increased dependency, decreased quality of life and autonomy, prolonged length of hospital stay, risk for nursing home admission and readmission, and increased need for professional health care at home. This also poses a major burden for families and informal caregivers.[1-10]

Functional decline, defined as a loss of the possibility to independently perform activities of daily living (ADL) such as bathing, dressing and toileting, and/or instrumental ADL (IADL), such as travelling, house cleaning and shopping, leads to a decreased functional status that also predicts further functional decline, the development of geriatric syndromes and other adverse events.[11-15] A functional decline is a geriatric syndrome that reflects a multifactorial etiology and different pathways leading to this negative functional outcome of hospitalization.[10, 13] In many cases, functional decline cannot simply be attributed to the acute medical problem for which a patient was hospitalized.[10]

The expanding older population needs effective health care focused not only on the prevention and treatment of diseases but also on effective interventions to prevent or delay a functional decline.[16, 17] Not all patients are at the same risk for the development of functional decline. This depends on the functional, physical and cognitive status of the individual and on the influence of external factors. The heterogeneity among older persons is substantial.[18-20] In order to prevent or delay a functional decline and to provide tailored and efficient patient care, it is necessary to identify those patients at a high risk for functional decline following hospitalization. This paper presents a discussion of the concept of functional decline and presents the development and validation of a prediction model to identify older hospitalized patients at risk for functional decline as the first step of prevention. Implications for clinical practice, for the education of health professionals, and recommendations for further research are made.

Ageing and functional decline

The consequences of demographic changes worldwide, with a continuously growing older population, pose a huge challenge. By 2025, about 28% of Europe's population and 21% of the population in the USA will be aged 65 years and over, and there will be a particularly rapid increase in the number of people aged 80 years and older.[21, 22] This will have an enormous impact on health care because the number of older patients admitted to the hospital will also increase.

Traditionally, the focus in health care is on the prevention and treatment of diseases. However, the demands of the older population are not limited to maintaining good physical and mental health but also require the promotion of independence and participation in society.[17, 23, 24] The preservation of independence (the ability to carry out daily self-care activities and live independently in one's own home) and autonomy (self-determination) and maintaining a good quality of life are important for everybody, and particularly for older persons.[25, 26]

Ageing is associated with physical effects such as a decline in muscle strength and aerobic capacity, diminished pulmonary ventilation, and a diminished quality of senses and skin integrity.[10] These changes increase the susceptibility to illnesses and hospitalization and could initiate a cascade of events and complications that could finally result in a diminished quality of life and increased dependency. In 1993, Creditor already proposed a model capturing the hazards of hospitalization of the elderly.[10] This model shows those factors related to the normal ageing process that is associated with hospitalization and bed rest that contribute to dependency (see Fig. 1).


Figure 1. The cascade to dependency.[10]

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Health and functional problems related to an older age, such as a cognitive and functional decline, visual and hearing problems, decreased mobility, and malnutrition, are commonly described as geriatric conditions and/or geriatric syndromes. Geriatric syndromes are multifactorial in cause, occur especially in vulnerable older adults, are precipitated by a variety of acute insults and are typically episodic in nature.[27] Inouye describes five geriatric syndromes: pressure ulcers, incontinence, falls, functional decline and delirium.[13] Several studies have shown an association between geriatric conditions and syndromes and poor health outcomes including functional decline.[13, 27-29]

Another common problem for older adults is the development of chronic diseases and the co-occurrence of multiple chronic diseases (multi-morbidity).[30-35] The presence of multiple diseases increases the likelihood of functional decline. As the number of diseases increases, the risk of difficulty performing ADL independently and decreasing mobility also increases. In a study of Marengoni for instance, the number of chronic diseases incrementally increased the risk of functional decline (hazard ratio from 1.5 in subjects with one chronic disease to 6.2 in persons with more than or equal to four diseases).[12, 36-39]

The normal process of ageing, the development of geriatric conditions and geriatric syndromes, and multimorbidity are all independently associated with a functional decline, but they also amplify the effects when they occur in combination. Older adults each have an individual mix of the elements of ageing; this and the genetic features of an individual explain the heterogeneity of the older population and the different risk among patients in developing functional decline. In the literature, older persons suffering one or more of these problems related to physical diminution are considered to be frail.[40] Frailty can be defined as a physiologic state of increased vulnerability to stressors that results from decreased physiologic reserves and even the deregulation of multiple physiologic systems. Frailty is a state of high vulnerability for adverse health outcomes, including disability, dependence, falls, need for long-term care and mortality.[40-42]

In 2007, Inouye describes a conceptual model that shows four shared risk factors (older age, cognitive impairment, functional impairment and impaired mobility) leading to geriatric syndromes, which in turn lead to frailty. Feedback mechanisms enhance the presence of shared risk factors and geriatric syndromes leading to the final outcomes of disability, dependence and death (see Fig. 2).[13]


Figure 2. A unifying conceptual model demonstrates that shared risk factors might lead to geriatric syndromes, which might in turn lead to frailty. Feedback mechanisms enhancing the presence of shared risk factors and geriatric syndromes. Such self-sustaining pathways might result in poor outcomes involving disability, dependence, nursing home placement and ultimately death, thus holding important implications for elucidating pathophysiological mechanisms and designing effective intervention strategies.[13]

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Both models, Creditor and Inouye, show the complex etiology of functional decline. There is not one single pathway leading towards functional decline, and the causes are multifactorial.

The iatrogenic aspects of hospital admission, such as bed rest, are a burden for older patients resulting in an acceleration of problems related to ageing and a loss of functional capacity.[43, 44] For patients admitted to a hospital who are already suffering geriatric conditions and syndromes, the development of new complications and an increase of geriatric syndromes (like delirium, falls, incontinence or pressure ulcers) are serious threats during hospital stay. These complications in turn will contribute to the development of a functional decline and will result in a prolonged length of stay with more threats.

Prevention starts with recognizing those vulnerable patients who are at risk for functional decline. The question is whether it is possible to identify older patients who are at risk for functional decline at the time of hospital admission because of the complexity of this multifactorial event and the heterogeneity of the older population.

Data sources

The identification of at-risk patients is based on estimating the probability of the development of functional decline. Prognostic research rests on principles and methods to develop prediction models based on the clinical and non-clinical profiles of the individuals in the targeted group, which are aimed at addressing the variability among patients and thus uses a multivariable approach.[45] The performance of a model may be assessed in terms of calibration (Hosmer–Lemeshow test) and discrimination ((area under the receiving operation curve (AUC)),.[46] Calibration is a way to compare the actual presence of functional decline after hospital admission with the predicted functional decline. Discrimination indicates the extent to which the model distinguishes between patients with or without functional decline.

To determine a prediction model to recognize patients at risk for functional decline, we performed a literature review to assess the availability and utility of prediction models.[47] Three screening instruments were found: the identification of seniors at risk (ISAR), which has six items and was developed and validated in Canada in patients in several emergency departments;[48] the care complexity prediction instrument (COMPRI), which has 13 items and was developed in the Netherlands to predict complexity in care for hospitalized patients;[49] and the hospital at risk profile (HARP), which has 29 items and was developed in six acute care hospitals in the USA.[50] We compared the discriminative values of these instruments in a cohort study (n = 177). The sensitivity, specificity and AUC for the ISAR were 93%, 39% and 0.67, respectively. The corresponding results for the COMPRI were 70%, 62% and 0.69, and for the HARP, they were 21%, 89% and 0.56.[51]

Given these results, in combination with the feasibility of using these instruments in clinical practice, the next step was the further development of the ISAR to be focused on improving the positive predictive value and specificity in the population of acutely hospitalized older patients. A multicenter cohort study in patients acutely admitted to general internal medicine departments was performed (n = 492). We used a univariate regression to assign the relative weights of the six items of the ISAR and additional predictors of functional decline from previous studies related to personal factors (such as age and socio-economical status) and personal responses to the ageing process (such as visual and hearing problems, decreased mobility, functional and cognitive status).[20, 52-56] The best performing predictors were used in a multivariate logistic regression. This resulted in the ISAR—hospitalized patients (ISAR-HP), a simple model with only four predictors (one predictor from the original ISAR), which made it easy to use in daily clinical practice: the pre-admission need for assistance in IADL, use of a walking device, need for assistance in travelling, and no education after age 14[57] (see Table 1). A score of ≥ 2 means the patient is at risk for developing functional decline.

Table 1. The identification of seniors at risk—hospitalized patients (ISAR-HP), a screening instrument to predict functional decline in older hospitalized patients[57]
  1. Total score 0 or 1 = not at risk.

  2. Total score ≥ 2 = patient is at risk for functional decline. IADL, instrumental activities of daily living.

Circle the figure behind the right answerYesNo
1. Before hospital admission, did you need assistance for IADL on a regular base? (like assistance in housekeeping, preparing meals, shopping, etc.)10
2. Do you use a walking device? (like a cane, rollator, walking frame, crutches, etc.)20
3. Do you need assistance for travelling?10
4. Did you pursue education after age 14?01
Total score (circled figures) 

Two of these predictors concern IADL (need for assistance in IADL and travelling), and one is an example of limited mobility (use of a walking device). These findings support the results of other studies showing that a lower functional status ADL and IADL were two of the five most-described predictors of functional decline, and other more recent studies showing that functional impairment and impaired mobility are important risk factors for the development of functional decline.[14, 15, 58, 59] Also, in the original ISAR, two of the six predictors were concerning a lower functional status (ADL en IADL) before admission.[48] The predictor ‘no education after age 14’ is an indicator of the socio-economic status of a person, also a well-known factor of health quality and a known predictor of functional decline.[31, 60] The AUC of this model was 0.71. At a threshold 2, the sensitivity, specificity, positive and negative predictive values were 87, 39, 43 and 85%, respectively. This positive outcome was supported by the results in a validation study in an independent population (n = 482). The AUC was 0.68, and the sensitivity, specificity, positive and negative predictive values were 89, 41, the 41 and 89%, respectively. Even in a completely different population, for patients > 70 years of age admitted for cardiac surgery (n = 475), this prediction model showed an AUC of 0.72, supporting the generalizability of the prediction model.[61]

Approximately two-thirds (70%) of the patients were identified as being at risk. For these patients, a comprehensive geriatric assessment was indicated. Based on this assessment, preventive and targeted interventions can be applied, thus enhancing the quality of care for older vulnerable patients. Our studies also show that about one-third of the patients do not need this special care, thus enhancing the efficiency of care.

Given the heterogeneity of our study populations and the results of the two validation studies (an independent and a new population), the conclusion is that the prediction model ISAR-HP shows a good capacity to predict a functional decline in older hospitalized patients and will be easy to use in clinical practice. The strength of the model is that it relies on four simple questions to predict a functional decline, an otherwise multifactorial and complex event.

Discussion and implications for clinical practice, education and research

Functional decline as a result of hospitalization is a serious threat for older individuals as it has a high impact on the quality of life and health-care demands. Hospitalization can, contrary to what people expect, change the prognosis of older persons in a negative sense by changing their life from independent to dependent. The prevention of functional decline could then be realized using a three-step model: first, identification of patients at risk; second, a comprehensive geriatric assessment; and third, targeted interventions for those patients at risk.

Our study shows that with four simple questions, patients at-risk for a functional decline can easily be identified at hospital admission. This enables the separation of those patients who need more than regular care from those for whom regular hospital care will be sufficient. For those at risk, further steps to tailor preventive interventions can be taken.

The exact clinical pathway to functional decline is still unknown, as is the degree to which decline can be prevented. The scientific evidence on the effect of the comprehensive geriatric assessment and tailored interventions continues to accumulate. Should one further invest in research regarding these issues, or should one continue to put effort in changing practice?

The origin of the studies described in this manuscript is in the problems faced in clinical practice. Because of their ability to observe and guide patients and the overall views they have, nurses should play a key role in the strategies to prevent functional decline. Recently, the results of a qualitative study regarding nursing care for delirious older patients were published.[62] The study showed a lack of knowledge, negative beliefs and attitudes in combination with a context in which the challenge of care for older people was hardly addressed. Other studies regarding care for older hospitalized patients found comparable results.[63, 64]

After the development of the ISAR-HP, we developed a three-step tailored care programme to improve care for the older patients within an academic service partnership (a linkage between academic nursing schools and hospitals). The three steps to prevent functional decline were described based on the evidence from literature, existing protocols and guidelines, and the expertise of staff nurses, clinical nurse specialists, and other experts. The ISAR-HP was introduced and, in patients at risk, a geriatric assessment was done by nurses guiding targeted interventions. The programme enhances the transition of available research evidence combined with a best practice into clinical practice, optimizes the use of existing resources and creates an inspiring learning environment for professionals and students in nursing. The participation of staff nurses in the development of the programme, education, clinical leadership and support by the managers was the basic element of effective implementation. The project showed that cooperation in an academic service partnership is an efficient way to bridge the gap between research, education and clinical practice.

Many of the students who were involved in the project are at this time active professionals participating in professional organizations and/or studying in master programmes. Working within the project made them aware of the challenges of the nursing profession and of the possibility to make a difference in the care of older people.

Given the growing number of older people in Western society and the growing need for care, any action to prevent functional decline, and thus to prevent or delay long-term care needs, cannot be withheld. A hospital admission is a moment in the continuity of people's lives; the shift in focus on the medical problem causing the admission to the continuity of daily living should be made in practice, in education and in further research. The coming older generation will be more aware of the importance to stay independent and autonomous.

We must not wait; we can make it happen today. As Goethe (1749–1832) wrote, Knowing is not enough; we must apply. Willing is not enough, we must do. The focus should not be only to gain more knowledge and insight. Much is known already; it is time for action.


  1. Top of page
  2. Abstract
  3. Introduction
  4. Background
  5. References
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