International Classification of Functioning-Based Analysis of Activity Limitations and Participation in Hospitalized Elderly Patients in Poland: A Cross-Sectional Study

Introduction

Population aging, characterized by a growing proportion of people in the oldest age groups, is a global phenomenon. This trend is primarily driven by demographic changes, particularly increases in life expectancy. The number of people aged 65 and over worldwide is expected to increase from 761 million in 2021 to 1.6 billion in 2050 [1]. At the end of 2023, according to the Polish Central Statistical Office, there were 9.9 million elderly people in Poland, and this is predicted to increase to 12.4 million by 2050 [2]. People aged 80 and over constitute an increasingly large group of the total population of Poland, and the health care system is not adapted to their needs and their specific medical conditions. People aged 80 and over living in south-eastern Poland have a high overall level of disability, and age, loneliness, low physical activity, and the growing number of chronic diseases are factors that affect its increase [3].

The increased burden of chronic disease and the coexistence of major geriatric syndromes make hospitalized older adults a population at particular risk for functional decline [4]. The process of hospital care, including polypharmacy and the associated risk of iatrogenic effects, prolonged bed rest, and general debilitation due to impaired health status, can inhibit the return to pre-hospital functional independence [5]. According to Covinsky et al, more than 50% of people aged 85 years and older at hospital discharge have additional limitations in basic activities of daily living as a result of hospitalization [6].

Assessment of health status and functional capacity is a key element in evaluation of hospitalized elderly patients. Baseline assessment of factors related to health and functional capacity is clinically important to identify deficits and therapeutic goals to be achieved during hospitalization. It should also be a priority for health policy to establish individual care plans, delay dependency, and promote active aging after hospitalization [7].

Although functional assessment tools exist for older people, most only consider the ability to perform activities of daily living or physical function. Previous studies have shown that a comprehensive assessment that incorporates the views and experiences of different professionals is effective in improving the functional survival of older people. Authors of previous studies also agree that the use of standardized tools is helpful in conducting multicenter studies and developing benchmarks in geriatric rehabilitation [8]. As pointed out by Zhang et al, there is a lack of reports in the literature on universal functional assessment tools that provide a comprehensive assessment of body structure and function, activity and participation, and environmental factors in the elderly population [9].

This can be achieved by using the International Classification of Functioning, Disability and Health (ICF), developed by the World Health Organization (WHO) in 2001. The ICF articulates a biopsychosocial model of health and provides a comprehensive and standardized description of disability. An important advantage of the ICF classification is that it considers the interactions between body structures and functions, their impact on activity and participation in daily life, and the environment in which a person functions [10]. According to the ICF, functioning is a key component of an individual’s health, and is influenced by environmental factors that can facilitate or hinder the performance of daily activities and participation. Activity is the ability to perform a single task from a physical point of view, but participation also includes the social context [11]. The ICF component “activity and participation” can describe all aspects of mobility (chapter d4) that are crucial for successful aging [12]. Such an assessment is particularly important for patients in geriatric wards to assess early on the possibility of returning home, the level of care required in that environment, or to consider an institutional form of further treatment or care after the end of the hospital stay. Therefore, an ICF-based assessment has the potential to provide the basis for implementing practical solutions for the complex planning of post-hospitalization support for dependent older people [13,14].

The WHO has proposed the use of the ICF model to describe functioning when assessing the health status of older people. To facilitate the clinical use of the ICF, core sets have been proposed as a framework for measuring the most important aspects of patients’ functional status and for capturing meaningful clinical change [15]. According to the review by Karlsson et al, there is a lack of validation studies for existing ICF core sets, which is crucial for their implementation in real clinical settings or for describing functional information in the general population [16]. Based on the literature review, no studies were identified regarding the assessment of activity and participation of people in the oldest age groups staying in geriatric wards based on the ICF. Therefore, the present study aims to address the gap in the literature by assessing activity limitations and participation restrictions, as well as the factors associated with them, among older adults hospitalized in an acute geriatric ward in south-eastern Poland. The following research questions were asked in the study:

Material and Methods

STUDY DESIGN AND SETTING:

A cross-sectional study was conducted between January and September 2019 to assess the relationship between activity and participation limitations and contextual factors in patients admitted to the geriatric ward of the Przeworsk Hospital (Podkarpackie Province, Poland) [17]. Approval to conduct the study was obtained from the Bioethics Committee of the University of Rzeszów (Resolution No. 2/12/2018). In accordance with the Declaration of Helsinki (updated in 2013 in Fortaleza, Brazil), potential participants were informed of the purpose of the study and of the rights they would have because of their participation. To comply with ethical principles when obtaining informed consent to participate in the study, considering the specificity of the population, only people with normal cognitive status were included, written information and forms to be signed were prepared in an appropriately larger font, and potential participants with visual and hearing deficits were asked to bring glasses and hearing aids. Those who agreed to participate signed an informed consent form. The study followed the guidelines of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement [18].

PARTICIPANTS:

The study included elderly people admitted to the geriatric ward of Przeworsk Hospital for acute care. Inclusion criteria for the study were: a) age 80 years and older, b) elderly not in institutional care, and c) no cognitive impairment (Abbreviated Mental Test Score >6 points). Exclusion criteria were: a) presence of severe systemic disease, b) acute inflammation, c) severe exacerbations of the disease, and d) lack of patient consent to participate in the study.

SAMPLE SIZE:

According to the available statistics, there were 3383 people aged 80 years and older in the region where the collaborating hospital was located [19]. The sample size calculation considered the average hospitalization rate in geriatric wards in the Podkarpackie province (south-eastern Poland), which was 88.03 per 100 000 inhabitants [20]. Based on these data, the sample size was calculated using the Online Sample Size Calculator (available at: https://www.calculator.net/sample-size-calculator.html). Assuming a 95% confidence level and a 5% margin of error, the minimum number of participants required was 281 (Figure 1).

VARIABLES:

The variables considered in this study were: a) contextual factors potentially associated with post-hospitalization disability in this population, and b) description of disability experienced by older people admitted to the acute geriatric hospital.

Contextual factors included sociodemographic characteristics (age, sex, place of residence, education and marital status), general typology, general health status, and health satisfaction of the participants. The description of disability was circumscribed to the ICF component “activities and participation” and ICF qualifiers were used to assess the severity of limitations.

CONTEXTUAL FACTORS:

Sociodemographic data included: a) age, b) sex, c) place of residence, d) education, and e) marital status. This information was collected using a structured questionnaire and was also used to characterize the sample.

Individuals’ general typology was assessed using body mass index (BMI), which is a measure recognized by the WHO for categorizing people by the relationship between their mass and height [21].

Participants’ general health status was measured by recording the level of pain using a Numeric Rating Scale (NRS) [22], the total number of medications taken per day, and the occurrence of falls in the past year.

Health satisfaction was assessed by the general question “Are you satisfied with your health?” Responses to this question were divided into 2 groups: at most neither dissatisfied nor satisfied, and at least satisfied. Similarly, quality of life was assessed by the general question “How is your quality of life?” The answers to this question were divided into 2 groups: at most neither good nor bad, and at least good. Older people’s health satisfaction and quality of life are key to subjective well-being and healthy aging [23].

ACTIVITIES AND PARTICIPATION: This ICF component was assessed using a tailored set of 20 ICF entities that was developed to evaluate levels of dependency during the project “Professionalization of assistance and care services for dependent people” [24]. The included entities were: d160 Focusing attention; d175 Solving problems; d177 Making decisions; d210 Undertaking a single task; d230 Carrying out daily routine; d350 Conversation; d410 Changing basic body position; d415 Maintaining a body position; d420 Transferring oneself; d440 Fine hand use; d445 Hand and arm use; d450 Walking; d510 Washing oneself; d530 Toileting; d540 Dressing; d550 Eating; d560 Drinking; d630 Preparing meals; d640 Doing housework, and d710 Basic interpersonal interactions.

Due to the setting of the study, the qualifier “capacity,” which describes an individual’s ability to perform a functional task in a standardized setting, was used to assess the level of limitation of these ICF entities. ICF qualifiers (0–4) were used to categorize the severity of the problem, where 0 is NO problem (0–4%); 1 is MILD problem (5–24%); 2 is MODERATE problem (25–49%), 3 is SEVERE problem (50–95%); and 4 is COMPLETE problem (96–100%) [10].

To analyze the extent of the problem of each ICF entity, the disability index described by Oliveira et al was used [25]. This index illustrates the percentage of the subject’s problem using ICF entities calculated from the sum of the qualifiers of all component categories. To facilitate the interpretation of the result, the sum obtained was transformed as follows: the sum of the qualifiers was divided by the maximum value of the component in question and then multiplied by 100. The resulting index indicates the percentage of the problem that an older person has in each component examined. The score ranges from 0 to 100, with the highest score indicating total problem/impairment of the component studied [26].

DATA COLLECTION:

Data were collected on the day of admission to the geriatric ward of Przeworsk Hospital. The method used to collect information was a structured interview conducted by trained physical therapists. The examination was conducted in a separate room with no third parties present, and the average examination time per patient was 30 minutes. To ensure that the process was consistent, the physiotherapists attended workshops on the goals and methods of using the ICF in assessing the health status of adults. The methodology for assessing the patient’s health condition was presented by members of the National Council for the Implementation of the International Classification of Functioning, Disability and Health.

STATISTICAL ANALYSIS:

Data were analyzed using TIBCO Statistica version 13 data analysis software (TIBCO Software Inc, 2017, and Statistica data analysis software system, version 13. http://statistica.io). The number and percentage (%) of categorical variables or the mean±standard deviation (SD) of measurable variables were used for the initial data analysis. The normality of the distribution of the measurable variables was tested using the Shapiro-Wilk test. Due to the non-normality of the distribution of the measurable variables, the Spearman rank correlation coefficient significance test (when sociodemographic variables were quantitative) or the Mann-Whitney U test (when sociodemographic variables were qualitative and included 2 categories) was used to assess the effect of each sociodemographic variable on the disability index in the study population. A linear regression model was used to examine the combined effect of the factors on the disability index. Regression coefficients with confidence intervals and corresponding levels of significance for the coefficients are reported. The level of statistical significance was set at P<0.05.

Results

The study included 281 elderly people, 168 of them were women (59.79%) and 113 men (40.21%), aged 80–97 years (mean age, 84.8 years). The majority of participants (76.87%) lived in rural areas. The average pain score in the study group was 3.17. More than 40% had experienced a fall in the past year. At least a good quality of life was reported by 53.02% of the respondents and only 36.30% of the respondents said they were at least satisfied with their health. There were no missing data for any of the study outcome measures. The characteristics of the study group are shown in Table 1.

Table 2 shows the prevalence of activity limitations and/or participation restrictions according to the ICF qualifier scale. The most restricted activities in the study group were Walking (d450), Undertaking a single task (d210), and Carrying out daily routine (d230). For these activities, severe problems were found in 45.20%, 28.83%, and 18.86% of respondents, respectively. A total problem was found in the area of Doing housework (d640) in 24.20% of respondents, Preparing meals (d630) in 8.90%, and Washing oneself (d510) in 8.19%. The most frequent lack of problems of the ICF categories surveyed were reported in the activities of Eating (d550) and Drinking (d560).

Table 3 shows the relationship between the disability index, calculated for the ICF component “activity and participation”, and contextual factors. The disability index for activity and participation increased significantly with age. Older people who had not experienced a fall had a significantly lower disability index in the activity and participation categories. Subjects with a lower self-rated health status and quality of life had a significantly higher disability index in the ICF activity and participation categories than subjects with the opposite self-rated health status and quality of life.

Table 4 shows an assessment of the combined effect of selected sociodemographic factors on the disability index. The disability index increases by an average of 0.92 points for each additional year of life. On average, people who had never fallen had a disability index 2.47 points lower than those who had fallen. People who rated their quality of life as neither good nor bad increased their disability index by an average of 3.31 points, while people who rated their health satisfaction as neither good nor bad increased their disability index by an average of 4.15 points.

Discussion

LIMITATIONS:

The study has some limitations that should be considered. First, it was a cross-sectional study that lacks causal inference and the results should be interpreted with caution. To improve the validity of the results, it would have been necessary to establish a cohort and carry out long-term follow-up. Second, the method of group selection limits the representativeness of the study, as the participants were from only one region of Poland. In addition, the study did not include people living in institutionalized conditions, which means that the results cannot be generalized to the entire population of older people. It was recognized that the daily functioning of people living in institutionalized conditions differs significantly from people living in a home environment due to the care, nursing support provided, and physiotherapy often provided, which may affect the final state of their functioning and condition too much heterogeneity of the study group. Nevertheless, there is a need for studies assessing activities and participation using ICF instruments in populations of older people living in institutionalized conditions, to enriching the state of knowledge in this area with new relationships. Third, information on the process of development and validation of the set of ICF entities used in this study is limited. Although it was derived from a project aiming at incorporating the ICF into the assessment of the dependency in older people, the results are not available in English, so some bias may have been introduced. The study design did not include the implementation of the inter-rater reliability of the assessments conducted by physiotherapists. Further research should validate and evaluate the ICF-based health status assessment in different populations and contexts and from different perspectives.

GENERALIZABILITY AND PRACTICAL IMPLICATIONS:

This study is the first in Poland and one of the few in the world to assess the prevalence of activity limitations and participation restrictions using the ICF among older people hospitalized in an acute geriatric hospital. The classification and its system of qualifiers combine flexibility and a common metric for comparability.

The use of ICF in clinical practice enables comprehensive and systematic documentation of an individual’s actual health experience. The information obtained from this research can influence decisions regarding the management of clinical practice, the dimensioning of support services considering the areas with the greatest limitations of the individual, and improvement of eldercare policy based on evidence from scientific research.

The ICF introduces a universal language that is understandable to all health care professionals to describe an individual’s functioning, which influences the ability to make international comparisons. The process of medical care for elderly patients should support the maintenance of independence in terms of activity and participation in social life for as long as possible.

Conclusions

The most common activity limitations in the study group were found in the ICF entities of Walking, Undertaking a single task, and Carrying out daily routine. The most relevant contextual factors were age, incidence of falls, self-assessment of quality of life, and satisfaction with one’s health. These findings may provide an indication for extending the standard comprehensive assessment procedure in acute geriatric hospitals with additional ICF-based instruments. Activity limitations and participation restrictions in older people are associated with some non-modifiable and modifiable factors. Policy-makers and health care workers should consider modifiable factors when planning systemic healthcare services for older people, such as physical exercise programs to prevent falls, training in creating safe living spaces for older people, training in activities of daily living, implementing systemic care and assistance services in the place of residence, and psychosocial support, which are key to maintaining independent living for people in the oldest age groups.