The main finding in this study was the independent association between ADL function at admission and in-hospital mortality in geriatric patients with pneumonia. We examined the role of ADL function at admission as a predictor of in-hospital mortality in geriatric patients with pneumonia. Hitherto, association between ADL function at admission and in-hospital mortality in geriatric patients with pneumonia has not been studied, and our study had relatively adequacy sample size. We noted that a low BI was associated with increased in-hospital mortality. In our study logistic regression analyses demonstrated that ADL function at admission was significantly and independently associated with the in-hospital mortality, we also adjusted for age group to evaluate differences in patients of different ages, the ADL function was found to be independently associated with the in-hospital mortality either in younger (age 65–74 years) or very elderly (age ≥ 75 years) patients. ROC curve analysis revealed that BI at admission is an important predictor related to in-hospital mortality in elderly patients, rather than consciousness impairments and systolic blood pressure. The prognostic value of ADL function at admission was good, as shown by the ROC curves.
CAP continues to be an important problem with a 30-day mortality rate as reported of 6.7–25% [6, 14–15]. In-hospital mortality rate for severe community-acquired pneumonia (SCAP) remains unacceptably high, range from 17 to 49% in large multicentre cohort studies [16–17]. The in-hospital mortality observed in this study was 2.7%, again in line with a multicenter study on adult admissions reporting rates 2.2% [18], while other study reporting in-hospital mortality 1–5% [19–20]. A range of risk assessment and preventive interventions are recommended to identify patients at high risk and implementing strategies for preventing functional which considered preventable risk factors.
Predicting the outcome and identifying potentially modifiable risk factors for pneumonia in elderly patients is crucial in clinical decision making. Jason Phua[21] found that early and aggressive management measures, implemented and valuation of prognosis within 24 hours decrease mortality in severe CAP. Different prognostic scales have been documented to assess in CAP, the most commonly be used are the PSI and CURB- 65. Carmen Gonzalez [22]found that the PSI prediction sensitivity in 28-day mortality is 82% and specificity is 34%, while, sensitivity of CURB-65 is 45% and specificity is 81%. PSI includes demographic parameters, comorbidities, physical examination and laboratory/imaging findings [23]. In contrast is the CURB-65 (Confusion, Urea nitrogen, Respiratory Rate, Blood pressure, Age > 65 years) [24]. These variables above in PSI and CURB-65 were included in this study. Variables in IDSA/ATS severe pneumonia criteria[12] were also included in the study, as the following: mechanical ventilator, tachypnoea, hypoxaemia, multilobar infiltrates, hypothermia, hypotension and WBC, PLT. These are known risk factors for mortality were included in our study, and in-hospital mortality are also likely to be associated with activities of daily living functional. However, both the PSI and the CURB-65, in contrast to our study data on ADL functional status was lacking. The relationship between comorbidities and survival was found in previously study [25]. However, comorbidities was not found to be a significant risk factor for in-hospital mortality by logistic analysis in our study, except for lung cancer in our study.
ADL function declines is associated with increased mortality [26–28]. Function declines is part of the process of healthy state change from risk factors, loss of function and diseases. The death of frail elderly with pneumonia is not frequently only due to pneumonia itself [29]. Even little changes in the ADL function could lead to poor clinical outcomes [30–31]. ADL functional status has been shown to be an independent predictor of mortality in heterogeneous populations [7–11]. In CAP, a worse ADL is directly related to increased immediate and long-term mortality [32]. It was reported that a BI level༜80 was associated with 30-day mortality in pneumonia patients [33] and a low BI with increased mortality in institutionalized patients[34]. On the other hand, a high BI level has been reported was related to reduced 30-day and 18 months mortalities in elderly CAP patients[35]. It was found that BI was one of the risk factors for 6 month mortality in COPD patients[36].While, a worse baseline BI was reported associated with greater mortality in elderly patients admitted to the emergency because of fever [37].
Our study show the same trend as all these previous studies, ADL decline is associated with increased risk of in-hospital mortality among elderly patients hospitalized with CAP. Assessment of ADL at admission in combination with the pneumonia severity scale could potentially be used in further management of CAP in geriatric patients. Barthel index (BI) can effectively performed to evaluate ADL. Barthel index is a widely used functional assessment of ADL. BI is the official ADL tool of geriatric patients. All patients admitted to ward were evaluated in our hospital. The Barthel Index (BI) is reliable, simple, and it can be used as a conventional method for the assessment of the ADL functional status at admission in geriatric patients with CAP to identify patients at high risk and conducive to clinical decision making.
The cause of behind ADL function and in-hospital mortality have not been clarified. The association of nutritional status and psychological with patient’s activities of daily living has been attention recently. Decreased activities of daily living functional was shown to be associated with the reduced muscle mass [38]. Elderly people with impaired ADL function may lose the ability to brush teeth, which may increase aspiration pneumonia [39]. In addition, studies have reported association between increased inflammatory markers and functional disability [40].
The study has some limitations. The first is the retrospective design of the study which resulted in some variables cannot be extracted from the electronic medical records. This study was conducted in a single hospital serving an urban area. It would be interesting to extend these observations in a larger sample and multicenter. Secondly, BI has some limitations, that may be influenced by the environment. Thirdly, it is unknown if specific measures such as exercise or nutrition supplementation, could improve activities of daily living function outcomes to improve prognosis in this high-risk subgroup of geriatric patients with pneumonia patients.