Abstract
Aim
To evaluate the ability of the Short Physical Performance Battery (SPPB) for predicting 1-year adverse outcomes of acutely ill older outpatients.
Methods
Prospective study with 512 acutely ill older outpatients (79.4±8.3 years, 63% female) in an acute care day hospital. The SPPB was administered at admission. Participants were classified as low (0–4 points), intermediate (5–8 points), or high (9–12 points) performance. Primary outcomes were new dependence in basic activities of daily living (ADL), hospitalization, and death at 1 year. Cox models tested whether the SPPB predicted outcomes after adjustment for sociodemographic factors, comorbidities and well-known geriatric conditions. We also estimated whether the chair-stand and balance tests improve the SPPB's ability to identify patients at high risk of adverse outcomes.
Results
Patients with intermediate or low SPPB performance were at higher risk of 1-year new ADL dependence (32% vs 13%: adjusted hazard ratio [aHR]=2.00; 95%CI=1.18–3.37; 58% vs 13%: aHR=3.40; 95%CI=2.00–5.85, respectively), hospitalization (43% vs 29%: aHR=1.56; 95%CI=1.04–2.33; 44% vs 29%: aHR=1.80; 95%CI=1.15–2.82), and death (18% vs 6%: aHR=2.54; 95%CI=1.17–5.53; 21% vs 6%: aHR=2.70; 95%CI=1.17–6.21). Use of all three components (versus gait speed alone) improved predictions of new ADL dependence (Harrell's C=0.73 vs 0.70;P=0.01), hospitalization (Harrell's C=0.60 vs 0.57;P=0.04), and death (Harrell's C=0.67 vs 0.62;P=0.04).
Conclusions
The SPPB is as a powerful tool for identifying acutely ill older outpatients at high-risk of adverse outcomes. The combination of the three components of the SPPB resulted in better predictive performance than gait speed alone.
Key words: Acute care, gait speed, geriatric day hospital, prognosis, short physical performance battery
Introduction
Physical performance has been recognized as a crucial element of intrinsic capacity in older adults (1). Among the available measures of physical function, the Short Physical Performance Battery (SPPB) combines gait speed, a chair-stand test, and a balance test. The SPPB was initially validated as a practical tool for identifying community-dwelling older adults at high risk for disability, hospitalization, and death (2, 3). These findings have encouraged further studies in other settings (4). More recently, the SPPB was shown to predict length of stay, post-discharge disability, and death among older adults admitted to acute medical wards (5, 6, 7, 8).
While there is compelling evidence favoring the utility of SPPB in hospital settings, little is known about its value for identifying acutely ill older outpatients at risk of hospitalization (4). In such a growing population, geriatric syndromes (e.g., nutritional status, cognitive and functional impairment, depressive symptoms) and the cumulative burden of diseases interacting with acute problems demand comprehensive assessments to detect underlying risks and define priorities in the context of limited time and resources (9, 10, 11). Considering that physical performance measures can help clinicians assess older patients' health statuses (12, 13), the easy-to-use SPPB would be a useful tool in fast-paced healthcare settings for the identification of vulnerabilities beyond those captured by sociodemographic factors, comorbidity, and other common geriatric conditions.
In this study we investigated whether the SPPB adds prognostic value to well-known risk factors for 1-year new dependence in basic activities of daily living (ADL), hospitalization, and death among acutely ill older outpatients. Because considerable controversy persists over whether gait speed alone performs as well as the complete SPPB (14, 15, 16), we also estimated the usefulness of the full SPPB over gait speed alone for predicting adverse outcomes.
Methods
Design, setting, and participants
This prospective cohort study comprised a consecutive sample of acutely ill outpatients aged 60 years and older in need of intensive management (e.g., intravenous therapy, imaging, and laboratory tests) to avoid full-time hospitalization in the academic medical center at the University of Sao Paulo Medical School, Brazil. Patients from ambulatory settings, emergency departments, home care, and primary health care units were referred to this acute care day hospital focused on short-term treatment as an alternative to emergency department visits and hospital admission. This public healthcare service operates 12 hours per day and treats patients with different acute medical conditions or exacerbations of chronic diseases, including infections, symptomatic congestive heart failure, acute anemia, uncontrolled hypertension, decompensated diabetes and refractory pain. Further details about the geriatric day hospital's routine are described elsewhere (17).
Between May 2014 and December 2015, a research team composed of a geriatrician, registered nurse, social worker, and pharmacist conducted the baseline assessment of patient admissions. During this period of time, a total of 618 acutely ill older adults were referred to the day hospital. We excluded patients requiring immediate hospitalization (n = 41), in palliative care (n = 26), definitely bedridden (n = 55), and refused to participate (n = 14). Thus, the study sample consisted of 512 individuals. All participants provided written informed consent. The study protocol was approved by the local ethics committee.
Short Physical Performance Battery
A research member assessed three components of lower-body function that constitutes the SPPB: balance test, usual gait speed and chair-stand test (2). Each SPPB test is scored from 0 to 4, with 0 representing inability to perform the task and 4 representing the highest performance. For the balance test, the participants had to stand in three positions for 10 seconds each: (1) with their feet side-by-side; (2) semi-tandem (the heel of one foot alongside the big toe of the other foot); and (3) tandem (the heel of one foot in front of and touching the other foot). For the assessment of gait speed, the participants were instructed to walk 4.5 m at their usual pace. The time to complete the path was registered. We considered the best of two performances. For the chair-stand test, participants were required to stand up and sit down five times as quickly as possible with their arms folded across their chests. We recorded the time as soon as patients started the first movement (bending forward at their hips) until they sat down after the fifth repetition. The global SPPB score was calculated by addition of the points of the three tests (range, 0–12), with higher scores indicating better function. The participants were classified into three groups according to the global SPPB score: low (0–4), intermediate (5–8), and high (9–12) performance (8).
Covariates
The research team also administered a comprehensive assessment to adjust the effect of possible confounders, including sociodemographic factors (age, sex, race, household income and availability of help), and geriatric syndromes. The Charlson Comorbidity Index served as a measure of multimorbidity (18). Nutritional status was assessed using weight loss in the last year. The Katz index measured ADL dependence (19). Cognitive status was assessed using the Mini-Mental State Examination (MMSE) (20). The 15-item Geriatric Depression Scale (GDS-15) was used to investigate depressive symptoms (21).
The professionals responsible for the patients' care had no access to the study information, which was managed using research electronic data-capture software (REDCap) (22).
Outcomes
Investigators blinded to the baseline assessment conducted monthly telephone interviews for 1 year after the first visit to the day hospital. The outcomes were new dependence in ADL, hospitalization, and death. New dependence in ADL during the follow-up period was identified in participants who needed help in a previously preserved ADL (i.e., eating, transferring, dressing, toileting, and bathing) compared to baseline. Hospitalization was defined as staying 24 hours or more in a hospital; the examiners registered the date of hospital admission. In cases of death, information about the leading cause and date was obtained from the patient's next of kin. We successfully contacted all participants in the follow-up assessments. Older adults who were alive and did not develop an outcome of interest were censored at the end of 1 year.
Statistical analyses
For comparison sociodemographic factors and geriatric syndromes among the three SPPB groups, we used one-way analysis of variance for numerical variables and the chi-squared test for categorical variables. Cumulative incidence curves using Kaplan-Meier estimates were computed for the adverse outcomes according to the three SPPB performance groups at baseline. The log-rank test was used to assess differences between the curves. Nested Cox proportional hazard models estimated whether the SPPB predicted the adverse outcomes when added to models already containing sociodemographic factors (age, sex, race, income), comorbidities, and other geriatric measures (Katz index, MMSE, GDS-15). The Wald's chi-squared test verified the impact of the SPPB on model fit.
We also assessed the association of each SPPB test (graded from 0 to 4) with the adverse outcomes using Cox regression models. Two nested models were fitted for the outcomes: (1) gait speed alone; and (2) gait speed, chair-stand test, and balance test (full SPPB). Finally, we calculated differences between the Harrell's C indexes of gait speed alone and full SPPB for new dependence in ADL, hospitalization, and death to investigate the impact of using the full SPPB on outcome discrimination (23).
All analyses were performed using STATA (version 14; Stata Corp., College Station, TX, USA). The Schoenfeld residual test confirmed the proportional hazard assumption of the models. Significance was set at an alpha level of 0.05.
Results
The mean (SD) patient age was 79.4 (8.3) years; 324 (63.3%) were female, and 323 (63.1%) were white (Table 1). The primary causes of referral to the day hospital were decompensated diabetes (20.1%), acute anemia (15.8%), symptomatic congestive heart failure (12.1%), and infection (10.9%). Participants had a mean SPPB global score of 6.2 (3.7) points and 52 (10.7%) participants were not able to walk. Regarding SPPB categories, 180 (35.2%) patients were classified as low performance, 157 (30.6%) as intermediate performance, and 175 (34.2%) as high performance. At baseline, a lower SPPB score was associated with older age, female sex, more comorbidities and depressive symptoms, any dependence in ADL, and worse nutritional status and cognitive performance (Table 1).
Table 1.
Baseline characteristics of participants according to Short Physical Performance Battery (SPPB) performance (N = 512)
| All Participants (n = 512) | High Performance SPPB 9–12 (n = 175) | Intermediate Performance SPPB 5–8 (n = 157) | Low Performance SPPB 0–4 (n = 180) | P value* | |
|---|---|---|---|---|---|
| Demographic characteristics | |||||
| Age (years), mean (SD) | 79.4 (8.3) | 75.3 (7.2) | 80.4 (8.1) | 82.8 (7.8) | <0.001 |
| Female sex, n (%) | 324 (63.3) | 99 (56.6) | 96 (61.1) | 129 (71.7) | 0.010 |
| White race, n (%) | 323 (63.1) | 104 (59.4) | 101 (64.3) | 118 (65.6) | 0.602 |
| Annual household income (per capita) | 0.045 | ||||
| <4000 USD, n (%) | 117 (22.9) | 39 (22.3) | 31 (19.8) | 47 (26.1) | |
| 4000–8000 USD, n (%) | 257 (50.2) | 76 (43.4) | 87 (55.4) | 94 (52.2) | |
| >8000 USD, n (%) | 138 (26.9) | 60 (34.3) | 39 (24.8) | 39 (21.7) | |
| Availability of help | 438 (85.5) | 139 (79.4) | 136 (86.6) | 163 (90.6) | 0.094 |
| Clinical characteristics | |||||
| Charlson Comorbidity Index | <0.001 | ||||
| 0–1 points, n (%) | 172 (33.6) | 85 (48.6) | 41 (26.1) | 46 (25.6) | |
| 2–3 points, n (%) | 189 (36.9) | 58 (33.1) | 66 (42.0) | 65 (36.1) | |
| ≥4 points, n (%) | 151 (29.5) | 32 (18.3) | 50 (31.8) | 69 (38.3) | |
| Any dependence in ADL, n (%) | 134 (26.2) | 5 (2.9) | 31 (19.7) | 98 (54.4) | <0.001 |
| Weight loss in the last year | 194 (37.9) | 47 (26.9) | 52 (33.1) | 95 (52.8) | <0.001 |
| 15-item GDS, mean (SD) | 4.9 (3.2) | 3.7 (2.7) | 5.3 (3.1) | 6.0 (3.3) | <0.001 |
| MMSE, mean (SD) | 21.1 (6.8) | 24.3 (4.6) | 22.2 (5.6) | 16.9 (7.5) | <0.001 |
SD = standard deviation; ADL, activities of daily living (eating, transferring, dressing, toileting, and bathing); MMSE, Mini-Mental State Exam; GDS, Geriatric Depression Scale; *P values represent comparison among the three SPPB groups using one-way analysis of variance for numerical variables and the chi-squared test for categorical variables.
During the 1-year follow-up, 168 (33.9%) older patients developed new dependence in ADL, 195 (38.1%) were hospitalized, and 76 (14.8%) died. Kaplan-Meier curves showed higher incidences of new ADL dependence, hospitalization, and death among the participants classified as having intermediate or low performance on the SPPB (Figure 1). After the adjustment for sociodemographic factors, comorbidities, and other geriatric syndromes, older adults classified as having low or intermediate performance on the SPPB had a higher risk of new dependence in ADL, hospitalization, and death compared with the high performance patients (Table 2). Adding SPPB to the models containing sociodemographic factors, comorbidity, and other geriatric measures markedly improved the model fit for the three adverse outcomes (Table 2).
Figure 1.
Cumulative Incidence of (A) New Dependence in ADL, (B) Hospitalization, and (C) Death According to Different Grades of Short Physical Performance Battery (SPPB) at baseline (N=512)
Table 2.
Association between Risk Factors and 1-Year Adverse Outcomes among Acutely Ill Older Outpatients and the Impact of Adding the Short Physical Performance Battery (SPPB) on Model Fit (N = 512)
| Hazard Ratio (95% confidence interval) | |||||||
|---|---|---|---|---|---|---|---|
| Characteristics | New dependence in ADL | Hospitalization | Mortality | ||||
| Model 1 | Model 2 | Model 1 | Model 2 | Model 1 | Model 2 | ||
| Age (years) | 1.04 (1.01–1.06) | 1.02 (1.00–1.05) | 0.99 (0.98–1.01) | 0.99 (0.97–1.01) | 1.02 (0.99–1.06) | 1.01 (0.98–1.05) | |
| Female | 0.84 (0.59–1.19) | 0.79 (0.55–1.10) | 0.55 (0.41–0.76) | 0.54 (0.40–0.74) | 0.52 (0.31–0.86) | 0.52 (0.30–0.85) | |
| White race | 1.03 (0.86–1.23) | 1.04 (0.87–1.24) | 0.95 (0.83–1.13) | 0.95 (0.81–1.11) | 0.98 (0.75–1.28) | 0.99 (0.76–1.29) | |
| Annual household income (per capita)† | 4000–8000 USD | 1.20 (0.78–1.83) | 0.78 (0.52–1.15) | 1.01 (0.69–1.45) | 1.00 (0.69–1.45) | 0.63 (0.34–1.10) | 0.61 (0.34–1.10) |
| <4000 USD | 1.60 (0.99–2.60) | 1.65 (0.39–1.06) | 0.92 (0.82–1.25) | 0.96 (0.84–1.25) | 0.49 (0.23–1.04) | 0.49 (0.23–1.05) | |
| Availability of help | 1.15 (0.88–1.49) | 1.14 (0.85–1.48) | 0.90 (0.75–1.08) | 0.90 (0.76–1.08) | 1.14 (0.75–1.73) | 1.10 (0.73–1.66) | |
| Charlson Comorbidity Index Score† | 2–3 points | 1.40 (0.91–2.09) | 1.39 (0.81–1.86) | 1.18 (0.81–1.70) | 1.09 (0.75–1.60) | 1.55 (0.78–2.95) | 1.38 (0.69–2.69) |
| ≥4 points | 1.45 (0.97–2.24) | 1.36 (0.84–1.96) | 1.44 (1.01–2.18) | 1.35 (0.91–1.99) | 1.75 (0.95–3.61) | 1.55 (0.80–3.12) | |
| Katz index (0–6) | 1.30 (1.19–1.45) | 1.22 (1.10–1.36) | 1.04 (0.97–1.18) | 1.00 (0.90–1.14) | 1.03 (0.92–1.25) | 0.98 (0.83–1.16) | |
| Weight loss in the last year | 1.16 (0.82–1.63) | 1.06 (0.75–1.50) | 1.57 (1.14–2.15) | 1.57 (1.15–2.14) | 1.67 (0.99–2.83) | 1.65 (0.97–2.78) | |
| MMSE (0–30) | 0.95 (0.92–0.98) | 0.96 (0.93–0.99) | 1.01 (0.98–1.04) | 1.02 (0.99–1.05) | 0.99 (0.93–1.03) | 0.99 (0.94–1.05) | |
| 15-item GDS (0–15) | 1.01 (0.96–1.06) | 0.98 (0.93–1.03) | 1.05 (1.01–1.11) | 1.04 (0.99–1.09) | 1.04 (0.96–1.12) | 1.01 (0.93–1.10) | |
| SPPB | High performance (9–12) | 1 | 1 | 1 | |||
| Intermediate performance (5–8) | 2.00 (1.18–3.37) | 1.56 (1.04–2.33) | 2.54 (1.17–5.53) | ||||
| Low performance (0–4) | 3.40 (2.00–5.85) | 1.80 (1.15–2.82) | 2.70 (1.17–6.21) | ||||
| Wald chi-square for change | P < 0.001 | P < 0.001 | P = 0.011 | P = 0.026 | P = 0.093 | P = 0.042 | |
ADL, activities of daily living (eating, transferring, dressing, toileting, and bathing); MMSE, Mini-Mental State Exam; GDS, Geriatric Depression Scale; Estimates were calculated using Cox proportional hazard models; Model 1: Sociodemographic factors (age, sex, race, income) + Charlson Comorbidity Index score + well-known geriatric measures (Katz index, MMSE, 15-item GDS); Model 2: Model 1 + SPPB; †The reference group for annual household income was >8000 USD, while for Charlson Comorbidity Index score was 0–1 point.
Table 2 shows the association between each SPPB test with 1-year adverse outcomes. Overall, the full SPPB had a significantly higher accuracy for discriminating new ADL dependence (Harrell's C = 0.73 vs 0.70; P = 0.01), hospitalization (Harrell's C = 0.60 vs 0.57; P = 0.04), and death (Harrell's C = 0.67 vs 0.62; P = 0.04) than gait speed alone (Table 3).
Table 3.
Association between Each Short Physical Performance Battery (SPPB) Test with 1-Year Adverse Outcomes among Acutely Ill Older Outpatients and the Impact of Full SPPB on Outcome Prediction (N = 512)
| Hazard Ratio (95% Confidence Interval)a | ||||||
|---|---|---|---|---|---|---|
| Performance in each test | New dependence in ADL | Hospitalization | Mortality | |||
| Gait speed alone | Full SPPB | Gait speed alone | Full SPPB | Gait speed alone | Full SPPB | |
| Gait speed test | ||||||
| ≤4.81 secs | 1 (reference) | 1 (reference) | 1 (reference) | 1 (reference) | 1 (reference) | 1 (reference) |
| 4.82–6.20 secs | 2.01 (1.18–3.44) | 1.48 (0.84–2.62) | 1.43 (0.94–2.18) | 1.17 (0.75–1.82) | 2.22 (1.06–4.67) | 1.51 (0.69–3.31) |
| 6.21–8.70 secs | 3.21 (1.98–5.20) | 1.60 (0.89–2.85) | 1.59 (1.07–2.37) | 1.24 (0.77–2.00) | 2.52 (1.24–5.12) | 1.24 (0.53–2.88) |
| ≥8.71 secs | 4.24 (2.64–3.81) | 1.64 (0.87–3.11) | 1.67 (1.11–2.49) | 1.22 (0.70–2.11) | 2.61 (1.29–5.31) | 1.01 (0.39–2.59) |
| Unable to walk | 9.77 (5.90–16.2) | 3.19 (1.52–6.73) | 1.72 (1.06–2.79) | 1.27 (0.62–2.62) | 3.73 (1.75–7.95) | 1.15 (0.38–3.50) |
| Chair-stand test | ||||||
| ≤11.19 secs | 1 (reference) | 1 (reference) | 1 (reference) | |||
| 11.20–13.69 secs | 1.38 (0.55–3.47) | 1.31 (0.64–2.65) | 1.92 (0.36–10.0) | |||
| 13.70–16.69 secs | 0.95 (0.36–2.50) | 2.03 (1.04–3.95) | 2.13 (0.42–10.8) | |||
| ≥16.70 secs | 1.92 (0.81–4.54) | 1.71 (0.89–3.28) | 3.94 (0.86–17.9) | |||
| Unable to complete | 2.38 (0.97–5.83) | 2.27 (1.13–4.54) | 6.10 (1.28–28.9) | |||
| Balance test | ||||||
| Tandem stand ≥ 10 secs | 1 (reference) | 1 (reference) | 1 (reference) | |||
| Tandem stand 3–9.99 secs | 1.06 (0.57–1.94) | 1.28 (0.82–2.01) | 1.05 (0.47–2.36) | |||
| Semi–tandem stand ≥ 10 secs | 1.75 (1.01–3.06) | 1.27 (0.81–2.01) | 1.11 (0.50–2.48) | |||
| Side–by–side stand ≥ 10 secs | 1.94 (1.12–3.35) | 0.99 (0.61–1.61) | 0.96 (0.42–2.17) | |||
| Side-by-side stand < 10 secs | 2.17 (1.18–4.00) | 0.95 (0.54–1.68) | 1.32 (0.55–3.17) | |||
| Harrell's C index | 0.70 (0.66–0.74) | 0.73 (0.69–0.77) | 0.57 (0.53–0.61) | 0.60 (0.56–0.64) | 0.62 (0.56–0.68) | 0.67 (0.61–0.72) |
| P value for comparison | ||||||
| Full SPPB — gait speed alone | P = 0.01 | P = 0.04 | P = 0.04 | |||
a. Estimates were calculated using Cox proportional hazard models; ADL, activities of daily living (eating, transferring, dressing, toileting, and bathing)
Discussion
The present study indicated that SPPB is an independent predictor of new dependence in ADL, hospitalization, and death among acutely ill older outpatients. Our results remained robust even after the adjustment for many confounders such as sociodemographic factors, comorbidities, and other geriatric conditions (nutritional status, depressive symptoms, cognition, and previous dependence in ADL). The findings also showed that the gait speed test combined with chair-stand test and balance test better identified acutely ill older adults at low and high risk of adverse outcomes than gait speed alone. We determined that the SPPB provided valuable prognostic information by detecting risk beyond that captured by standard anamnesis and well-known geriatric syndromes.
Physical performance proved a vital and early sign indicative of vulnerability that reflects several underlying physiological impairments (24). However, limited time and resources hinder the use of many available tools assessing physical performance in acute healthcare settings (25). Our results indicate that SPPB, an easy-to-administer instrument that combines three simple tests of lower limb function, can be a feasible method to assess physical performance in acutely ill older patients.
Older adults, especially those who are frail, presenting with acute medical conditions and exacerbations of chronic diseases manifest nonspecific symptoms and signs that usually include decreased mobility and balance (26, 27). The physical function impairment degree was highly correlated with acute event severity and the individual's physiologic reserve (28). Our results determined that even those older adults with modest lower body functional impairments — classified as intermediate performance on the SPPB — presented high vulnerability to disability, hospitalization, and death after short-term acute care. Previous studies in the hospital setting did not detect a high risk of adverse outcomes among individuals with medium scores on the SPPB, indicating that deficits in physical performance may represent an element of risk still more sensitive in outpatient settings (6, 7, 8).
Different from other studies in use of the SPPB for acutely ill patients, we administered the instrument on admission. Assessing physical performance early in the course of an acute condition can help clinicians understand the patient's ability to recover from a stressful situation (29, 30). Hatheway et al. proposed that acutely ill older adults presenting with early improvements in physical function showed better prognosis than those who maintained mobility and balance deficits (27). An early assessment of lower limb physical capability with the addition of balance and chair-stand tests to gait speed could be a promising method for tracking the degree of recovery from acute problems in older people.
This study has some strengths. First, we demonstrated that SPPB can be implemented in a real-world scenario of acute care. Second, we obtained complete information from all participants without attrition during the 1-year follow-up period. Third, we compared the performance of full SPPB with gait speed alone for three different clinical outcomes. Finally, our analysis considered a high number of risk factors and highlighted the prognostic utility of SPPB in outpatient healthcare settings. Some limitations should also be noted. First, therapeutic interventions in the day hospital may have impacted the performance of the SPPB by reducing the incidence of outcomes. Second, although acutely ill older adults at risk of hospitalization are a common population, acute care settings vary considerably across healthcare systems, thus limiting the external validity of our findings. Finally, build on a single medical center, our results should be confirmed in other representative samples.
Conclusion
In conclusion, the SPPB, with its three practical lower limb performance tests, is an effective tool for stratifying the risk of adverse outcomes in acutely ill older adults at risk of hospitalization.
Funding
This study was supported by Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) and Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) (2014/50007-4).
Declarations of interest
None.
Ethical Standards
The authors declare that the study procedures comply with current ethical standards for research involving human participants and follows the principles outlined in the Declaration of Helsinki. The study protocol was approved by the Ethics Committee of the University of Sao Paulo Medical School (Brazil).
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