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Trajectories of Life-Space Mobility After Hospitalization

Cynthia J. Brown, MD, MSPH; David L. Roth, PhD; Richard M. Allman, MD; Patricia Sawyer, PhD; Christine S. Ritchie, MD, MSPH; and Jeffrey M. Roseman, MD, PhD, MPH
[+] Article and Author Information

From the Birmingham and Atlanta Veterans Affairs Geriatric Research, Education, and Clinical Center and the University of Alabama at Birmingham, Birmingham, Alabama.


Acknowledgment: The authors thank Teresa D. Tennyson for her role in data collection and project coordination, Eric V. Bodner for his assistance with data management, and all the participants who took part in the UAB Study of Aging.

Grant Support: By a Veterans Affairs Research Career Development Award (E4-3842VA) (Dr. Brown) and a John A. Hartford Foundation-funded Southeast Center of Excellence in Geriatric Medicine Special Fellows grant (Dr. Brown). The UAB Study of Aging is funded through a grant from the National Institute on Aging (R01 AG015062).

Potential Financial Conflicts of Interest:Grants received: R.M. Allman (National Institute on Aging). Grants pending: R.M. Allman (National Institute on Aging).

Reproducible Research Statement:Study protocol: Not available. Statistical code: Available from Dr. Roth (droth@uab.edu). Data set: The limited data set from the first 3 years of the UAB Study of Aging is available from Dr. Sawyer (Patricia Sawyer, MD, UAB Center for Aging, 1530 3rd Avenue South, Birmingham, AL 35294-204).

Requests for Single Reprints: Cynthia J. Brown, MD, MSPH, Birmingham Veterans Affairs Medical Center, 11G, 700 South 19th Street, Birmingham, AL 35233; e-mail, cbrown@aging.uab.edu.

Current Author Addresses: Dr. Brown: Birmingham Veterans Affairs Medical Center, 11G, 700 South 19th Street, Birmingham, AL 35233.

Dr. Roth: Ryals Public Health Building, 343B, 1530 3rd Avenue South, Birmingham, AL 35294-0022.

Drs. Allman, Sawyer, and Ritchie: CH-19, Room 201, 1530 3rd Avenue South, Birmingham, AL 35294-0041.

Dr. Roseman: Ryals Public Health Building, 210G, 1530 3rd Avenue South, Birmingham, AL 35294-0022.

Author Contributions: Conception and design: C.J. Brown, R.M. Allman, P. Sawyer.

Analysis and interpretation of the data: C.J. Brown, D.L. Roth, R.M. Allman, P. Sawyer, C.S. Ritchie, J.M. Roseman.

Drafting of the article: C.J. Brown, D.L. Roth.

Critical revision of the article for important intellectual content: C.J. Brown, D.L. Roth, R.M. Allman, P. Sawyer, C.S. Ritchie.

Final approval of the article: C.J. Brown, R.M. Allman, P. Sawyer, C.S. Ritchie.

Provision of study materials or patients: R.M. Allman.

Statistical expertise: D.L. Roth.

Obtaining of funding: R.M. Allman.

Collection and assembly of data: J.M. Roseman.


Ann Intern Med. 2009;150(6):372-378. doi:10.7326/0003-4819-150-6-200903170-00005
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Background: Life space is a measure of where a person goes, the frequency of going there, and the dependency in getting there. It may be a more accurate measure of mobility in older adults because it reflects participation in society as well as physical ability.

Objective: To assess effects of hospitalization on life space in older adults, and to compare life-space trajectories associated with surgical and nonsurgical hospitalizations.

Design: Prospective observational study.

Setting: Central Alabama.

Participants: 687 community-dwelling Medicare beneficiaries at least 65 years of age with surgical (n = 44), nonsurgical (n = 167), or no (n = 476) hospitalizations.

Measurements: Life-Space Assessment (LSA) scores before and after hospitalization (range, 0 to 120; higher scores reflect greater mobility).

Results: Mean age of participants was 74.6 years (SD, 6.3). Fifty percent were black, and 46% were male. Before hospitalization, adjusted LSA scores were similar in participants with surgical and nonsurgical admissions. Life-space assessment scores decreased in both groups immediately after hospitalization; however, participants with surgical hospitalizations had a greater decrease in scores (12.1 more points [95% CI, 3.6 to 20.7 points]; P = 0.005) than those with nonsurgical hospitalizations. However, participants with surgical hospitalizations recovered more rapidly over time (gain of 4.7 more points [CI, 2.0 to 7.4 points] per ln [week after discharge]; P  < 0.001). Score recovery for participants with nonsurgical hospitalizations did not significantly differ from the null (average recovery, 0.7 points [CI, −0.6 to 1.9 points] per ln [week after discharge]).

Limitation: Life space immediately before and after hospitalization was self-reported, often after hospital discharge.

Conclusion: Hospitalization decreases life space in older adults. Surgical hospitalizations are associated with immediate marked life-space declines followed by rapid recovery, in contrast to nonsurgical hospitalizations, which are associated with more modest immediate declines and little evidence of recovery after several years of follow-up.

Primary Funding Source: National Institute on Aging.

Figures

Grahic Jump Location
Figure 2.
Trajectory of adjusted life-space mobility decrease and recovery.

Estimated trajectories of life-space mobility on the basis of reason for admission, after adjustment for age, sex, race, rural or urban status, comorbid conditions, and independence with activities of daily living. Life-space mobility trajectories of participants hospitalized with a major surgical and nonsurgical admission are shown in green and black, respectively. The calendar time for a hospitalization was centered at the median time to a first hospital admission (1.95 years [25th, 75th percentiles: 1.03, 3.31]).

Grahic Jump Location

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These differences could be due to DHEA levels.
Posted on April 8, 2009
James M. Howard
independent
Conflict of Interest: None Declared

It is my hypothesis that DHEA was selected by evolution because it optimizes replication and transcription of DNA. Therefore, all tissues rely on DHEA for optimal function. DHEA naturally begins to decline around age twenty, reaching very low levels in old age. (This past week, it was reported that measurable mental decline actually begins in the twenties).

It follows that genes rely on DHEA levels for optimal function. As DHEA begins to decline, genes which are not "optimal," themselves, may begin to fail to express optimally as DHEA declines. I suggest this is the reason for an early "hump" in the chart of mortality and morbidity that occurs before the late "hump" which typifies old age. This includes many diseases which may be most dramatically exemplified by Parkinson's, Huntington's, and Alzheimer's diseases, to mention some of the brain-related diseases which, I think, are produced by the early loss of DHEA and malfunctioning genes.

The findings of Brown, et al., may be explained by the foregoing. That is, some surgeries may be required because of abnormalities of growth and development and "wear and tear." These may not be directly due to loss of DHEA of old age. However, many hospitalizations of old age, I suggest, are due to the loss of DHEA and, therefore, represent a failure of availability of DHEA as genes fail to operate. While surgery is known to temporarily reduce DHEA, which may trigger a "rebound," hospitalizations for "failure of available DHEA" will not produce a rebound.

Conflict of Interest:

None declared

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