The Correlation of Instrumental Activity Daily Living (IADL) Score

with Functional Outcome Status and Long-Term Rehospitalization

amongst Geriatric Patients

Lili Dwiyani, Melinda Harini

Department of Physical Medicine and Rehabilitation, Dr. Cipto Mangunkusumo General Hospital,

Faculty of Medicine, University of Indonesia, Jakarta, Indonesia

Keywords: Functional Outcome, Geriatric Patients, Instrumental Activity Daily Living (IADL), Long-Term

Rehospitalization

Abstract: Rehospitalizations amongst geriatric patients are increasing the health care burden. Nonetheless, we have

limited information on unplanned long-term rehospitalization. IADL is the more complex functional

capacity that usually decreasing before deficits in basic ADL. The aim of this study is to correlate the IADL

score before the first admission with functional outcome status and long-term rehospitalization amongst

geriatric patients. It is a cross-sectional study. Twenty-one database of geriatric patients with a history of

rehospitalization within one-year was included, which set in the geriatric inpatient ward in Cipto

Mangunkusumo Hospital. The decline of IADL was measured with Lawton’s score before first hospital

admission, the number of rehospitalizations was recorded during history taking, and functional outcome

status was assessed with modified Barthel Index (mBI) at discharge. Lower IADL decline before first

hospital admission was significantly correlated with higher mBI at rehospitalization discharge (r= -0.647;

p= 0.002), but poor correlated with the number of long-term rehospitalization (r = -0.09, p > 0.05). This

finding suggests that the independence of ADL at hospital discharge will be achieved if patients have a

higher IADL score before admission. Further study needs to be constructed about factors contributing to

long-term rehospitalization amongst geriatric patients.

1 INTRODUCTION

Among developed and developing countries, elderly

(aged over 60 years) make up a large proportion of

the population and many require hospitalization for

aging-related disease (Divo et al., 2016). Data from

Riset Kesehatan Dasar (Riskesdas) revealed that, as

of 2018, Indonesia has 9.27% proportions of elderly.

The report estimated that by the year 2050, more

than one in four persons living in Indonesia will be

older than 60 years (Silviliyana et al., 2018). Such a

demographic process will directly impact the

national healthcare system, with increasing needs for

care and important implication on direct healthcare

costs.

A geriatric is elderly who have more than one

medical condition and/ or comorbidities due to

decreased function of physical or psychological. In

Indonesia, more than 50% of geriatric have

experienced health complaints in a month due to

aging-related diseases, including hypertension,

arthritis, stroke, obstructive pulmonary disease, and

diabetes mellitus. These conditions caused 25.7% of

disability and 8.46% of hospital admission and/ or

readmission in one year (Silviliyana et al., 2018).

A number of studies have investigated geriatric

patient's hospitalization-related characteristics,

events, and outcomes. They focused on

rehospitalization prevention amongst geriatric

patients as a high-risk population. They found that

patient factors are possible predictors of

rehospitalization, such as age, gender, marital status,

insurance status, socioeconomic status, employment

status, living conditions, and functional impairment

252

Dwiyani, L. and Harini, M.

The Correlation of Instrumental Activity Daily Living (IADL) Score with Functional Outcome Status and Long-Term Rehospitalization amongst Geriatric Patients.

DOI: 10.5220/0009089002520258

In Proceedings of the 11th National Congress and the 18th Annual Scientiﬁc Meeting of Indonesian Physical Medicine and Rehabilitation Association (KONAS XI and PIT XVIII PERDOSRI

2019), pages 252-258

ISBN: 978-989-758-409-1

(Wong et al., 2011; Tonkikh et al., 2016). The

functional decline during hospitalization is

associated with 1.5 to 3 times greater likelihood of

rehospitalization (Hoyer et al., 2015; Greysen et al.,

2016).

Functional status refers to the ability to perform

self-care, self- maintenance, and physical activity.

Maintenance of functional status is an important

indicator of health in the elderly. The loss of this

capacity leads to a rise in morbidity and mortality

(Millan-Calenti et al., 2010).

Functional status is usually classified into two

types, basic activities of daily living (ADL) and

instrumental activities of daily living (IADL). ADL

are defined as activities that essential for an

independent life,while IADL are more complex

activities that require a higher level of personal

autonomy. These IADL-scores refer to tasks

implying enough capacity to make decisions as well

as greater interaction with the environment. Usually,

deficits in IADL precede deficits in ADL. However,

most of the studies measured the functional status of

geriatric patients using ADL.

The aim of this study is to correlate the IADL

score before the first admission with functional

outcome status and long-term rehospitalization

amongst geriatric patients. We hypothesized that the

lower decline of IADL at first hospital admission

negatively correlated with functional outcome status

at discharge and positively correlated with the

number of rehospitalization.

2 METHODS

We performed a cross-sectional study of the

Geriatric Division’s database which consecutively

included geriatric patients (aged over 60 years who

has more than one medical condition and/ or

comorbidities) that consulted to Medical

Rehabilitation Department. The database of in-

patient setting was Cipto Mangunkusumo Hospital

(Jakarta, Indonesia), particularly in geriatric inward.

We excluded database of patients that was the first

admission and/ or no history of rehospitalization

within one year, also the database that not include

complete information of patient’s functional status

(ADL and IADL), neither in the first admission nor

the latest discharge, and those who died during in-

patient care. The study was approved by the Ethics

Committee of the Faculty of Medicine, University of

Indonesia.

2.1 Data sources

All data were collected through an existing database

of Geriatric Division, Medical Rehabilitation

Department.

2.2 Variables and Instruments

2.2.1 Lawton’s Instrumental Activity Daily

Living (IADL) Score Before First

Admission

IADL was measured using Lawton’s score, which

consisted of 8 items including the ability to use the

telephone, shopping, food preparation,

housekeeping, laundry, mode of transportation,

responsibility for own medications, and ability to

handle finances. Each item is ranked on the 1-point

scale. The total scores are summarized into a total

score ranging from 0 (totally dependent) to 8 (fully

independent). We examined the change of IADL

before the first admission, defined as a decline of

IADL before the first acute hospital admission

within one year before the latest admission, that

reported by the patient or the caregiver and recoded

on the database.

2.2.2 Outcome Definition

Rehospitalization was defined as any unplanned

hospital admission related to the main diagnosis at

any hospital in Jakarta, that occur within one year

before the last admission. The number of

rehospitalization collected from history taking

section, either in present illness or past medical

history. If a patient was rehospitalized more than

once, each episode was counted as a separate

hospitalization.

Functional outcome status was assessed with

modified Barthel Index (mBI), consisted of 10 items

including personal hygiene, bathing, eating,

toileting, dressing, chair/ bed transfers, ambulation,

stair climbing, and bowel and bladder control. Each

item is ranked on a 2- point scale (except for transfer

and mobility which ranked on a 3-point scale),

indicating the amount of assistance required in

functional independence in each task. The scores are

summarized into a total score, ranging from 0

(totally dependent) to 20 (fully independent). The

information was given by the patient’s caregiver

before the latest hospital discharge and recoded on

the database.

The Correlation of Instrumental Activity Daily Living (IADL) Score with Functional Outcome Status and Long-Term Rehospitalization

amongst Geriatric Patients

253

2.3 Statistical Analysis

All analyses were performed using SPSS (Statistical

Package for Social Sciences, SPSS Inc., Chicago,

IL) version 20.0.

The sociodemographic characteristics were

systematized through descriptive statistics, using the

relative frequencies when the variables were

categorical. For continuous variables—functional

status, age, number of caregivers, and number of

rehospitalization—we used measures of central

tendency (means) and dispersion measures (standard

deviation).

To identify the correlation between the decline of

IADL score and both outcomes – the number of

rehospitalization and functional outcome status – a

bivariate analysis was performed. Prior to the

correlation analysis, normality in the distribution of

the variables was verified through the Shapiro-Wilk

test. Because IADL score as the predictor has a

normal distribution, we choose using Pearson

correlation test to analyze the association between

variables. It was conventionally used that r < 0.2

indicates a poor association; between (0.21; 0.50)

fair; between (0.51; 0.70) moderate; between (0.71;

0.90) very strong; and finally, between (0.91;

1.00) a perfect association. To compare the global

IADL score and each domain IADL according to

gender, we choose using the Fisher test. For the tests

performed, the lower limit of significance was set

at p < 0.05 (95% confidence level), and the null

hypothesis was rejected when the probability of

significance of the test (p-value) was lower than this

value

3 RESULTS

Of a total 45 database of Geriatric Division that

collected in the last four years (2015- 2019), 32 were

considered eligible. Of these number, 11 databases

were excluded because 7 of them were the first

hospital admission, 2 of them had no

rehospitalization history in the last one years, and

the last 2 had not complete information of patient’s

functional status (ADL and IADL), thus the total

number of sample in this study was 21.

Table 1: Clinical characteristics and demographics of geriatric patient’s database.

Variable Total (n= 21) Men (n=12) Women (n=9)

Age, years, mean + SD 67.0 + 5.98 67.67 + 6.47 66.11 + 5.51

Living alone, n (%) 1 (4.8) 0 (0) 1 (11.1)

Non-formal caregiver, n (%) 20 (95,2) 11 (91.7) 0 (0)

Education, n (%)

Elementary school

Junior high school

Senior high school

College or university

3 (14.3)

1 (4,8)

10 (47.6)

7 (33.3)

1 (8.3)

0 (0)

7 (58.3)

4 (33.3)

2 (22.2)

1 (11.1)

3 (33.3)

Last occupational status, n (%)

Unemployed

Government employees

Private employees

Entrepreneur

4 (19.0)

9 (42.9)

0 (0)

2 (16.7)

3 (25.0)

7 (58.3)

4 (44.4)

2 (22.2)

1 (11.1)

2 (22.2)

The main disease that caused

rehospitalization, n (%)

Diabetes mellitus

Heart failure

Chronic obstructive pulmonary disease

Malignancy

Autoimmune disease

9 (42.9)

2 (9.5)

1 (4.8)

8 (38.1)

1 (4.8)

4 (33.3)

2 (16.7)

1 (8.3)

5 (41.7)

0 (0)

5 (55.6)

3 (33.3)

0 (0)

1 (11.1)

Body structure/function that caused IADL

decline at first hospital admission, n (%)

Pain function

12 (57.1)

2 (9.5)

6 (50.0)

2 (16.7)

6 (66.7)

0 (0)

KONAS XI and PIT XVIII PERDOSRI 2019 - The 11th National Congress and The 18th Annual Scientiﬁc Meeting of Indonesian Physical

Medicine and Rehabilitation Association

254

Heart function

Lung function

Cognitive function

Gastrointestinal function

Metabolic function

1 (4.8)

3 (14.3)

2 (9.5)

1 (8.3)

0 (0)

2 (22.2)

1 (11.1)

Number of rehospitalization, mean + SD 1.71 + 0.902 1.67 + 0.778 1.78 + 1.093

IADL before first admission (1-8), mean +

3.90 + 2.02

4.33 + 2.35 3.33 + 1.41

IADL decline (1-8), mean + SD 4.10 + 2.02 3.67 + 2.35 4.67 + 1.41

ADL at latest hospital discharge (mBI) (0-

20), mean + SD

9.71 + 5.1 10.75 + 6.27 8.33 + 2.69

As shown in Table 1, the mean age of patients

was 67,0 years (standard deviation (SD) 5.98) and

most were men (57.14%). Almost all patients have

cared by non-formal caregivers who lived together

with them (95.2%). We tried to descriptively

investigate the main disease that caused the

rehospitalization of geriatric patients as baseline

data, that was diabetes mellitus (42.9%), malignancy

(38.1%), heart failure (9.5%), chronic obstructive

pulmonary disease (4.8%), and autoimmune disease

(4.8%). We also evaluated what body structure/

function that impaired in the first hospital admission

that caused IADL decline, those were pain (57.1%),

gastrointestinal (14.3%), metabolic (4.8%), heart

(4.8%), lung (4.8%), and cognitive function (4.8%).

From eight domains of IADL, the mean IADL

and IADL decline before the first admission was

3.90 (SD 2.02) and 4.10 (SD 2.02), respectively.

Lower IADL decline before first hospital admission

was significantly correlated with higher functional

outcome (mBI) at discharge (r= -0.647; p= 0.002)

(Table 2), but poor correlated with long-term

rehospitalization (r = -0.09, p = 0.685) (Table 3).

Because historically there was a different

assessment of Lawton’s IADL in men and women,

we tried to describe each domain of IADL that

preserved before the first hospital admission for both

genders. After observing the activities assessed

according to gender, men present a higher global

average score than women (4.33 vs. 3.33), though

the difference is statistically not significant (p =

0.27). As shown in Table 4, the ability to use the

telephone (95.2%) and responsibility for own

medications (81.0%) were two domains that mostly

preserved in geriatric patients. Interestingly, men

were more independent in activities doing the

laundry (50.0% against 0% of women) (p = 0.017).

However, there were no differences (p>0.05) for

other continuous variables of clinical characteristics

and demographics between both genders, including

IADL decline, total IADL, age, number of

caregivers, and number of rehospitalization.

Table 2: The correlations of IADL decline with mBI in

geriatric patients

IADL Decline

mBI at last discharge p = 0.002 r = -0.647*

*Pearson correlation test

Table 3: The correlations of IADL decline with the

number of rehospitalization in geriatric patients

IADL Decline

Number of

rehospitalization

p = 0.685 r = -0.09*

*Pearson correlation test

4 DISCUSSIONS

The topic of unplanned rehospitalization prevention

amongst geriatric patients has received increasing

attention (Morandi et al., 2013). The major purpose

of this study is to examine whether the decline IADL

at the first hospital admission data can be used to

detect high-risk patients for unplanned long-term

rehospitalization and also to predict functional

outcome status at every hospital discharge.

To our knowledge, ours is the first study

investigating the correlation of functional status at

first hospital admission and unplanned long-term

rehospitalization (> 30 days). Previous studies

showed that at-admission functional status

associated with short-term unplanned

rehospitalization (Morandi et al., 2013; Tonkikh et

al., 2016). Interestingly, when we tried to correlate

the decline of functional status representing by

The Correlation of Instrumental Activity Daily Living (IADL) Score with Functional Outcome Status and Long-Term Rehospitalization

amongst Geriatric Patients

255

IADL at first hospital admission score with the

number of rehospitalization within one year, there

was a poor correlation between these two variables.

This discrepancy may due to many factors that

influence rehospitalization amongst geriatric

patients, especially in a long-term setting. Campbell

et al conducted a systematic review of factors

affecting the outcome in older medical patients

admitted to hospital, one of the outcome measures

was rehospitalization rate that influenced by

functional status score, illness severity, co-

morbidity, polypharmacy, diagnosis or presenting

illness, and age (Campbell, Seymour and Primrose,

2004).

Diabetes and malignancy are two main diagnoses

that underlie the rehospitalization of geriatric

patients in our study. Data from Health and Nutrition

Survey 2001, HANES III, approximately 20% of the

population develop diabetes by the age of 60

(Meneilly and Tessier, 2001) and it will nearly

double by 2025 (Bethel et al., 2007). Previous

studies suggest that there was a relationship between

glycemic control and hospital admission, which very

poor glycemic control (HbA1c > 10%) was

associated with a 2.13 times greater likelihood of

rehospitalization (Menzin et al., 2010). Patients with

Table 4: Domains of IADL that preserved in the first hospital admission according to gender, n(%)

Total (21) Male (12) Female (9) P value

Ability to use telephone 20 (95.2) 11 (91.67) 9 (100) 0.571

Shopping 4 (19.0) 2 (16.67) 2 (22.22) 0.586

Food preparation 5 (23.8) 4 (33.33) 1 (11.11) 0.258

Housekeeping 6 (28.6) 5 (41.67) 1 (11.11) 0.148

Laundry 6 (28.6) 6 (50.00) 0 (0.00) 0.017

Mode of transportation 12 (57.1) 7 (58.33) 5 (55.55) 0.623

Responsibility for own medications 17 (81.0) 9 (75.00) 8 (88.88) 0.414

Ability to handle finances 11 (52,4) 7 (58.33) 4 (44.44) 0.425

*Fisher test

diabetes who were rehospitalized within 1 year had

higher plasma glucose levels at admission (Dungan,

2012). Both the inpatient and outpatient settings of

glycemic control could potentially reduce the need

for rehospitalization. Therefore, the ideal discharge

therapy should be made that implemented with

knowledge of the pre-hospital and in-hospital

glycemic control, also considered the needs and

capabilities of the individual patient.

In the elderly with cancer, previous studies

suggested that functional status can predict survival,

chemotherapy toxicity, postoperative morbidity, and

mortality. The main goal of geriatric care in this

population is the improvement in the ability to

complete ADL, as well as an improvement in pain

and quality of life (Extermann and Hurria, 2007).

Our study found that pain was the most chief

complaint that brought cancer patients to an acute

hospital setting. During the data collection, the

available pain killer was found to be inadequate in

managing pain after hospital discharge. The

identification of this symptom focuses attention on

the need for improved management of pain as well

as enhanced patient and family education and

assessment. The patient should be educated about

the method to reduce pain, such as proper

medication usage. Assessment should include their

understanding of specific instructions, including

when to call the nurse or physician. These

preventive measures were expected to reduce the

number of rehospitalization among geriatric patients.

The other result of our study found that lower

IADL decline at first hospital admission is

negatively correlated with the functional outcome at

the latest hospital discharge. When geriatric patients

had lower IADL decline before the first hospital

admission, they will have better independency of

ADL at discharge. Efforts to maintain or improve

functional status, especially IADL, an outpatient

setting may be an important modifiable risk factor to

have better independence at the next hospital

discharge (Hoyer et al., 2015). Researchers had

demonstrated that elderly patients who received

occupational therapy services had significantly

better ADL and IADL performances compared to

patients who had not received these services

(Koketsu, 2018). Consequently, we suggest that

every hospitalized geriatric patient should get

KONAS XI and PIT XVIII PERDOSRI 2019 - The 11th National Congress and The 18th Annual Scientiﬁc Meeting of Indonesian Physical

Medicine and Rehabilitation Association

256

occupational therapy services during hospitalization

with the goal to establish or restore IADL ability at

discharge. This strategy should also be maintained in

outpatient setting with considering cultural, social,

and environmental factors of patient.

If we refer to the differences in gender and

Lawton’s IADL score of our study, men present a

higher average score than women. In general, this

result means men are more independent than women

in the assessed area, though these differences are not

significant statistically. Our finding is similar to the

previous study by Millan-Calenti et al that

investigating the relationship between gender and

functional dependence using the IADL score. But, if

we assessed for each domain of IADL, our study

found an interesting difference compared with the

previous study, thus women were more dependent

on activities doing the laundry. Traditionally,

women have been more bounded to domestic

activities including doing the laundry, housekeeping,

and cooking, thus they should be more independent

in these domains (Millan-Calenti et al., 2010).

Unfortunately, from clinical characteristics and

demographics data of our study still can not explain

this discrepancy. One hypothesis that we could

propose is the absence of IADL detail of our

database. When reviewing the original IADL form,

each domain of IADL should be recorded in detail.

For example in laundry ability, the elderly

considered independent (scored 1) when they can do

personal laundry completely or launders small items,

for example, rinse socks or stockings (Lawton and

Brody, 1969). This point should be a concern for

further research. The other limitation of our study

was the small number of sample sizes that possible

had less conclusive results and risk of recall bias

since functional status data at first admission and

hospital discharge were collected from participant’s

self-reports.

5 CONCLUSIONS

Patients with lower IADL decline before the first

admission will have better independency of ADL at

hospital discharge within one year. However, IADL

decline can not be a predictor of long-term

rehospitalization amongst geriatric patients. Further

study needs to be constructed about factors

contributing to long-term rehospitalization amongst

geriatric patients with focusing on detail IADL for

each domain.

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Medicine and Rehabilitation Association

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