Comprehensive assessment for hospital-acquired deconditioning in acute hospitals
overall performance can be readily quantified, and
expected population norms should also be developed.
Any new HAD assessment instrument also requires
extensive reliability testing. This was a critical omis-
sion in 5 of the included instruments. Information on
expected variability in performance of body systems
is urgently required over a typical inpatient hospital
stay, for different sex-age groups, so that abnormal
deterioration of body systems can be readily identified
(2, 4, 5, 7).
The development of a new comprehensive HAD as-
sessment instrument could be integrated with quality
care and discharge planning standards, and hospital
accreditation requirements (2–4, 14). It is counterin-
tuitive, and makes no economic, social or functional
sense to allow people to decondition whilst in hospital,
and to leave hospital in poorer health than when they
were admitted (1, 3–5). Regular application of a com-
posite test battery will identify incipient HAD before
it becomes an issue, and promote healthy ageing in,
and out of, hospital. It could also underpin integrated
inter-professional practice (14, 16). A comprehensive
assessment instrument should be able to be delivered
by any healthcare provider from any discipline (e.g.
doctor, nurse, physiotherapist, occupational therapist,
healthcare assistant). Because it uses a standard ap-
proach, the findings could then be readily understood
and discussed at inter-professional discharge planning
meetings for HAD risk identification and mitigation
strategies (6, 7, 9, 14).
Not all the Creditor HAD items were addressed in
the included assessment instruments (e.g. deminera-
lization (markers for osteoporosis), nutritional status/
usual food intake, sensory “continence”, urinary con-
tinence and polypharmacy) (12). Whilst items such
as balance, function, mobility, skin integrity could
readily be assessed and re-assessed over short time-
periods, measures such as demineralization, nutrition,
appetite, perceived health status, sensory deprivation
(hearing, vision, touch, taste, smell, etc.), osteoporosis
and polypharmacy are more appropriate to longer-term
reflective measurement periods (2, 4, 10). These mea-
sures lend themselves to comprehensive assessment on
hospital admission, to detect already declining function
and frailty (5). Moreover, proxy measures of demi-
neralization could be inferred from anthropometric
measures, mobility, balance and muscle strength, and
sensory “continence” is integral to successful comple-
tion of all physical tests (2, 4, 5). However, urinary (and
faecal) continence can change over short time-periods,
and thus its assessment should be included in any new
HAD instrument (34).
This systematic evidence scan identified that at least
12 tests of performance in different body systems are
403
required for comprehensive assessment for incipient
HAD (see Tables II and III). Whilst condition-specific
assessments were deliberately excluded in order to find
general HAD assessments, the included assessment
items could also be applied to people with known
chronic conditions to ensure that they do not decondition
whilst receiving care requiring bed rest.
Study limitations
The comprehensiveness of the search was potentially
limited by the lack of agreed characteristics of HAD,
against which assessment items from the identified
instruments could be aligned. Moreover, the breadth
of the evidence scan was potentially limited by incon-
sistencies in nomenclature describing deconditioning,
functional decline and frailty. The search may thus
have failed to identify all relevant HAD assessment
literature. The focus on general HAD assessment
items (non-condition-specific) may have limited iden-
tification of relevant items that had been developed
for chronic conditions or disease, but were, in fact,
transferable to global HAD assessment.
Conclusion
No single assessment instrument currently assesses
HAD comprehensively. HAD should largely be identi-
fiable with regular targeted, comprehensive assessment
of performance of multiple body systems, in order to
detect early changes. This would support preventative
interventions during the hospital stay and restorative
interventions on discharge.
REFERENCES
1. Gillis A, MacDonald B. Deconditioning in the hospitalized
elderly. Can Nurse 2005; 101: 16–20.
2. Falvey JR, Mangione KK, Stevens-Lapsley JE. Rethinking
hospital-associated deconditioning: proposed paradigm
shift. Phys Ther 2015; 95: 1307–1315.
3. Kleinpell RM, Fletcher K, Jennings BM. Chapter 11, Redu-
cing functional decline in hospitalized elderly. In: Patient
safety and quality: an evidence-based handbook for nur-
ses. Hughes RG, editor. Rockville: Agency for Healthcare
Research and Quality; 2008.
4. van Vliet M, Deeg DJH. Decreasing hospital length of stay:
effects on daily functioning in older adults. J Am Geriatr
Soc 2017; 65: 1214–1221.
5. Xue Q-L. The frailty syndrome: definition and natural
history. Clin Geriatr Med 2011; 27: 1–15.
6. Timmer AJ, Unsworth CA, Taylor NF. Rehabilitation in-
terventions with deconditioned older adults following an
acute hospital admission: a systematic review. Clin Rehabil
2014; 28: 1078–1086.
7. Gill TM, Gahbauer EA, Han L, Allore HG. Functional trajec-
tories in older persons admitted to a nursing home with
disability after an acute hospitalization. J Am Geriatr Soc
2009; 57: 195–201.
8. ICD-10-CM/PCS codes. [Accessed 2018 Jun 28]. Available
from: http://www.icd10data.com/About/.
J Rehabil Med 51, 2019