Abstract
Background
Acute decompensated heart failure (ADHF) often causes functional decline in older adults, leading to frailty and poor outcomes. This study aimed to identify factors linked to inadequate functional recovery during hospitalization and to assess how early in-hospital functional status predicts recovery at discharge.
Methods and Results
We enrolled 166 patients aged ≥75 years hospitalized for ADHF who had maintained basic activities of daily living before admission (Barthel Index [BI] ≥70). Functional status was assessed weekly during hospitalization using the BI. We then investigated the clinical factors associated with insufficient improvement in BI. Multivariable logistic regression analysis revealed that advanced age (odds ratio [OR] 1.11; 95% confidence interval [CI] 1.03–1.20; P=0.010), concomitant dementia (OR 3.17; 95% CI 1.34–7.52; P=0.008), and BI <50 1 week after admission (OR 4.94; 95% CI 2.07–11.80; P<0.001) were significantly associated with inadequate functional recovery (BI <70) at discharge. Furthermore, BI <50 1 week after admission was associated with higher cardiovascular mortality and rehospitalization for heart failure (HF) after discharge compared with those who improved (log-rank P=0.044).
Conclusions
In older patients with ADHF, advanced age, concomitant dementia, and insufficient BI improvement 1 week after admission were associated with inadequate functional recovery during hospitalization. Insufficient early functional recovery was also linked to adverse post-discharge outcomes. Therefore, early BI assessment may facilitate risk stratification for functional recovery at discharge in older HF patients.
Key Words: Barthel Index, Early rehabilitation, Heart failure, Older population, Physical frailty
Central Figure.
Heart failure (HF) is a major cause of hospitalization among older adults,1,2 and acute decompensation frequently precipitates a rapid decline in physical function; the effectiveness of cardiac rehabilitation in recovery is limited.3 This HF-related functional deterioration often exceeds expected aging-associated changes and represents a pivotal turning point that drives older individuals toward frailty.4,5 Once established, frailty markedly increases vulnerability to recurrent HF events, loss of independence, and early mortality. Functional status at discharge is one of the strongest predictors of post-discharge outcomes in HF, including rehospitalization, institutionalization, and death.6,7 Among available functional measures, the Barthel Index (BI) is widely used to quantify activities of daily living (ADL)8,9 and is sensitive to short-term changes during hospitalization. Prior studies consistently show that a low BI at discharge limits the effectiveness of cardiac rehabilitation and is associated with poor prognosis.10–12 Although BI at discharge is a strong prognostic marker, it captures only the final state of functional recovery. Risk stratification would be far more meaningful if patients likely to experience poor recovery could be identified earlier in their hospital course, when targeted interventions are still feasible.13 Despite the importance of functional recovery, little is known about how early during hospitalization functional status begins to diverge between patients who will recover when discharged and those who will not. It also remains unclear whether repeated BI assessments can identify the earliest time point when the discharge level function becomes predictable. Understanding this trajectory would allow clinicians to target rehabilitation, nutrition, and multidisciplinary care proactively before functional decline becomes irreversible.14 Therefore, in the present study, we conducted serial BI assessments throughout hospitalization in older patients admitted for acute decompensated HF (ADHF). Our objectives were to: (1) characterize the trajectory of functional recovery during hospitalization; (2) identify determinants of insufficient improvement in BI; and (3) determine the earliest in-hospital time point at which functional recovery at discharge can be reliably predicted.
Methods
Study Cohort and Data Collection
Consecutive 258 older patients (aged ≥75 years) who were admitted to our institution due to ADHF from March 2019 to April 2022 were screened. In our hospital, we attempt to evaluate BI in all patients aged ≥65 years who are hospitalized for HF at the time of admission and every week thereafter. The BI was evaluated by nurses and physical therapists specializing in HF rehabilitation. For the BI before hospitalization, information about the functional status of each evaluation item was collected from patients themselves and their caregivers, including family members living with them, and a comprehensive assessment was conducted. We defined a minimal level of functional independence sufficient to maintain home living in older HF patients as a BI ≥70, which was considered to reflect preserved abilities in ADL domains closely related to caregiving burden, including transfers, toileting, continence, and basic indoor mobility, and adopted these cut-off BI scores for relative independence in ADL in previous reports.15–17 We excluded 88 patients from this study for the following reasons: 53 patients who did not maintain physical function before admission (BI <70); and 35 patients for whom information on physical function before and after admission was unavailable. Additionally, we excluded 4 patients because we could not continue their HF treatment due to mental confusion within 1 week of admission. Last, this study enrolled 166 patients who maintained physical function (BI ≥70) before admission and received a BI assessment every week after admission (Figure 1). We also gathered information on patient characteristics, including age, sex, body mass index, history of hospitalization for HF, comorbidities such as hypertension, diabetes, hyperlipidemia, atrial fibrillation, ischemic heart disease, and dementia that had been diagnosed by a specialist or for which medical treatment had been initiated before admission, laboratory data including B-type natriuretic peptide (BNP) levels, estimated glomerular filtration rate (eGFR), hemoglobin levels, albumin levels, total cholesterol levels, and lymphocyte counts. In addition, we obtained information on treatment for ADHF: use of intensive care units, ventilator or non-invasive intermittent positive pressure ventilation (NIPPV), and inotropic treatment. Furthermore, we also collected patient information on the period of bed rest from the date of admission, the period until the start of bedside exercise therapy, the weekly change in the BI after admission, and the length of hospital stay. Last, we investigated adverse events for 1 year after discharge, which were defined as cardiovascular death and rehospitalization due to HF.
Figure 1.
Flowchart for patient enrollment. Consecutive 258 older patients (aged ≥75 years) who were admitted to our institution due to acute decompensated heart failure (ADHF) from March 2019 to April 2022 were screened. We excluded 88 patients from this study: 53 patients who did not maintain physical function (Barthel Index [BI] <70) before admission, and 35 patients for whom information on functional status before and after admission was unavailable. Additionally, we excluded 4 patients because we could not continue their HF treatment due to mental confusion within 1 week of admission. Finally, this study enrolled 166 patients who maintained functional status (BI ≥70) before admission and received a BI assessment every week after admission.
Contributing Factors to Insufficient Improvement in BI During Hospitalization
We defined BI ≥70 at discharge as functional recovery and compared patient characteristics between patients who recovered during hospitalization and those who did not. In addition, focusing on early functional recovery (1 week after admission), we investigated the association between early functional recovery and functional status at discharge. Regarding BI scores at admission, a substantial proportion of patients were unable to undergo BI assessment due to severe ADHF requiring strict bed rest, hemodynamic instability, or intensive medical management. Consequently, BI scores at admission were available primarily in patients with relatively stable HF conditions, introducing substantial missing data and potential selection bias. Because the BI at admission was not systematically assessed across the entire cohort, analyses examining the relationship between admission and discharge BI scores were not performed, as such analyses would not adequately reflect the overall study population. Using receiver operating characteristic (ROC) curve analysis, we determined the optimal cut-off value of the BI at 1 week after admission to predict functional recovery at discharge. Then, using multivariable logistic regression analysis, we investigated associated factors with inadequate functional recovery during hospitalization (BI <70 at discharge) among patient characteristics, information on treatment for ADHF and cardiac rehabilitation during hospitalization, and achievement of early functional recovery 1 week after admission. A multivariable logistic regression analysis was conducted by inputting significant factors identified in the univariable analysis. Last, we investigated the impacts of both functional status at 1 week after admission and at discharge on prognosis after discharge. We compared Kaplan–Meier event-free survival curves using the log-rank test between patients with functional recovery at discharge and those without, as well as between those with early functional recovery and those without, among patients who survived and were discharged.
Statistical Analysis
The BNP levels and lymphocyte counts were expressed in natural logarithms. Continuous data are presented as mean±standard deviation and compared using the t-test between groups. Categorical variables are summarized as frequencies and percentages and compared with the Pearson’s χ2 test or Fisher’s exact test. A P value <0.05 was considered statistically significant. This retrospective study was conducted in accordance with the Declaration of Helsinki and received approval from the Institutional Review Boards and Ethics Committees at all sites. We adopted an opt-out approach to notify eligible patients of the research use of their information before enrollment. All statistical analyses were performed with SPSS version 29.0 software (SPSS Japan Inc., Tokyo, Japan).
Results
Patient Characteristics
In Table 1, the clinical backgrounds of patients are presented and the parameters between patients with functional recovery (BI ≥70) and those without at discharge are compared. Among the study population, 6 deaths were confirmed. Three of these patients died within 1 week after admission. All deaths were included in the group with BI <70 at discharge. Compared with the patients with functional recovery at discharge, the patients who did not reach a BI of 70 were significantly older (84±5 vs. 87±6 years; P<0.001), had significantly more frequent occurrence of dementia (45.0% vs. 13.2%; P<0.001), and showed a significantly lower albumin level (3.3±0.4 vs. 3.5±0.5 g/dL; P=0.039). Regarding New York Heart Association functional class and information about inpatient treatment for ADHF, there was no significant difference between the 2 groups. In contrast, compared with patients with functional recovery at discharge, the period of bed rest for those without was significantly more extended (4 vs. 3 days [median]; P=0.002), and the period until they started bedside rehabilitation tended to be longer (5 vs. 4 days [median]; P=0.079). During hospitalization, 85.5% of all patients completed a cardiac rehabilitation program centered on exercise therapy, with no significant difference in the proportion between the 2 groups. Additionally, regarding the length of hospital stay (with a median of 19 days), there was no significant difference between the 2 groups.
Table 1.
Comparison of Clinical Backgrounds Between Patients With a BI ≥70 and Those With a BI <70 at Discharge
| All (n=166) |
BI ≥70 (n=106) |
BI <70 (n=60) |
P value | |
|---|---|---|---|---|
| Age (years) | 85±5 | 84±5 | 87±6 | <0.001 |
| Sex, male | 89 (53.6) | 59 (55.7) | 30 (50.0) | 0.519 |
| BMI (kg/m2) | 20.7±3.7 | 20.8±3.6 | 20.5±3.9 | 0.650 |
| History of hospitalization for HF | 33 (19.9) | 20 (18.9) | 13 (21.7) | 0.689 |
| HFrEF | 71 (42.8) | 44 (41.5) | 27 (45.0) | 0.744 |
| NYHA class | 0.477 | |||
| II | 10 (6.0) | 8 (7.5) | 2 (3.3) | |
| III | 75 (45.2) | 49 (46.2) | 26 (43.3) | |
| IV | 81 (48.8) | 49 (46.2) | 32 (53.3) | |
| Comorbidity | ||||
| Hypertension | 129 (77.7) | 80 (75.5) | 49 (81.7) | 0.439 |
| Diabetes | 57 (34.3) | 37 (34.9) | 20 (33.3) | 0.867 |
| Hyperlipidemia | 56 (33.7) | 32 (30.2) | 24 (40.0) | 0.233 |
| Atrial fibrillation | 80 (48.2) | 54 (50.9) | 26 (43.3) | 0.419 |
| Ischemic heart disease | 70 (42.2) | 42 (39.6) | 28 (46.7) | 0.416 |
| Dementia | 41 (24.7) | 14 (13.2) | 27 (45.0) | <0.001 |
| Laboratory data | ||||
| BNP (pg/mL) | 849.3 [517.8–1,377.6] | 840.7 [521.1–1,213.1] | 914.1 [520.6–1,391.0] | 0.593 |
| Log BNP (pg/mL) | 2.90±0.38 | 2.89±0.38 | 2.93±0.38 | 0.558 |
| eGFR (mL/min/1.73 m2) | 47.1±25.7 | 49.3±25.5 | 43.3±25.8 | 0.146 |
| Hemoglobin (mg/dL) | 11.3±1.8 | 11.5±1.8 | 11.1±1.7 | 0.257 |
| Albumin (g/dL) | 3.4±0.5 | 3.5±0.5 | 3.3±0.4 | 0.039 |
| Total cholesterol (mg/dL) | 149.8±36.0 | 149.7±33.3 | 150.0±41.1 | 0.973 |
| Lymphocytes (/μL) | 900 [700–1,300] | 1,000 [700–1,400] | 850 [600–1,200] | 0.056 |
| Log lymphocytes (/μL) | 2.98±0.24 | 3.01±0.23 | 2.94±0.25 | 0.060 |
| Treatment for acute decompensated HF | ||||
| Use of intensive care units | 77 (46.4) | 45 (42.5) | 32 (53.3) | 0.197 |
| Ventilator or NIPPV support | 33 (19.9) | 19 (17.9) | 14 (23.3) | 0.423 |
| Inotropic treatment | 22 (13.3) | 10 (9.4) | 12 (20.0) | 0.061 |
| Cardiac rehabilitation | ||||
| Period of bed rest (days) | 3 [2–6] | 3 [2–5] | 4 [3–8] | 0.002 |
| Period until starting bedside rehabilitation (days) | 4 [2–8] | 4 [2–7] | 5 [3–8] | 0.079 |
| Completion of rehabilitation program | 142 (85.5) | 89 (84.0) | 53 (88.3) | 0.499 |
| Length of hospital stay (days) | 19 [13–30] | 18 [13–27] | 23 [14–34] | 0.138 |
Data are presented as n (%), median [IQR], or mean±SD. Numeric values are expressed as the mean±standard deviation or median [interquartile range (IQR)]. BI, Barthel Index; BMI, body mass index; BNP, B-type natriuretic peptide; eGFR, estimated glomerular filtration rate; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; NIPPV, non-invasive positive pressure ventilation; NYHA, New York Heart Association.
Trajectory of BI After Admission
Figure 2 shows the trajectories of BI for the 2 groups after admission (Figure 2A for all patients and Figure 2B for the patients discharged after 2 weeks of hospitalization). Differences in the week-to-week trend of BI were observed between the 2 groups from the first week after admission. Patients with functional recovery at discharge showed a significant increase in BI during the first week after admission (63.8±24.1 vs. 29.7±18.8; P<0.001; Figure 2A; 54.9±23.2 vs. 29.4±17.9; P<0.001; Figure 2B, respectively), which remained higher than that of the other group from the first week onward. Distribution of BI scores at each point during hospitalization for ADHF of the study patients is shown in the Supplementary Figure. According to ROC curve analysis of all patients, a BI of 50 in the first week after admission was the optimal cut-off value for predicting functional recovery at discharge, with a sensitivity of 90.0% and a specificity of 67.9% (area under the curve 0.852; P<0.001).
Figure 2.
(A) Comparison of trajectory of Barthel Index (BI) after admission between patients with a BI ≥70 and those without at discharge (all patients). We compared the trajectory of BI recovery after admission between patients with a BI ≥70 (black) and those without at discharge (red) across all study patients. Differences in the week-to-week trend of BI were observed between the 2 groups from the first week after admission. Patients who recovered to a BI ≥70 at discharge showed significantly higher BI values in the first week after admission, and this improvement persisted from the first week onward compared with those who did not. (B) Comparison of trajectory of the BI after admission between patients with a BI ≥70 and those without at discharge (patients discharged after 2 weeks of hospitalization). We also compared the trajectory of BI recovery after admission between patients with a BI ≥70 (black) and those without at discharge (red) among patients discharged after 2 weeks of hospitalization. This patient group consists of 114 patients out of the total 166 enrolled patients, excluding 3 patients who died within 1 week of admission and 49 patients who were discharged within 2 weeks of admission. Differences in the week-to-week trend of BI were also observed between the 2 groups from the first week after admission. Patients who recovered to a BI ≥70 at discharge showed significantly higher BI values in the first and second week after admission.
Clinical Backgrounds Associated With Inadequate Functional Recovery at Discharge
According to the univariable logistic regression analysis, higher age, concomitant dementia, lower albumin levels, extended bed rest period, and a BI of <50 at 1 week after admission were significantly associated with inadequate functional recovery at discharge. Furthermore, the multivariable analysis demonstrated that higher age, concomitant dementia, and a BI of <50 at 1 week after admission were significantly associated (age: odds ratio [OR] 1.11; 95% confidence interval [CI] 1.03–1.20; P=0.010; concomitant dementia: OR 3.17; 95% CI 1.34–7.52; P=0.008; BI <50 at 1 week after admission: OR 4.94; 95% CI 2.07–11.80; P<0.001, respectively; Table 2).
Table 2.
Associated Clinical Backgrounds With Inadequate Functional Recovery (BI <70) at Discharge
| Univariable | Multivariable | ||
|---|---|---|---|
| P value | Odds ratio (95% CI) | P value | |
| Age (years) | <0.001 | 1.11 (1.03–1.20) | 0.010 |
| Sex, male | 0.483 | ||
| BMI (kg/m2) | 0.468 | ||
| HFrEF | 0.662 | ||
| History of hospitalization for HF | 0.664 | ||
| NYHA class ≥III | 0.286 | ||
| Hypertension | 0.358 | ||
| Diabetes | 0.838 | ||
| Hyperlipidemia | 0.200 | ||
| Atrial fibrillation | 0.346 | ||
| Ischemic heart disease | 0.378 | ||
| Dementia | <0.001 | 3.17 (1.34–7.52) | 0.008 |
| Log BNP (pg/mL) | 0.555 | ||
| eGFR (mL/min/1.73 m2) | 0.151 | ||
| Hemoglobin (mg/dL) | 0.256 | ||
| Albumin (g/dL) | 0.042 | 0.737 | |
| Total cholesterol (mg/dL) | 0.973 | ||
| Log lymphocytes (/μL) | 0.064 | ||
| Use of intensive care units | 0.178 | ||
| Ventilator or NIPPV support | 0.403 | ||
| Inotropic treatment | 0.059 | ||
| Period of bed rest (days) | <0.001 | 0.051 | |
| Period until starting bedside rehabilitation (days) | 0.164 | ||
| Completion of rehabilitation program | 0.443 | ||
| BI <50 at 1 week after admission | <0.001 | 4.94 (2.07–11.80) | <0.001 |
CI, confidence interval. Other abbreviations as in Table 1.
Impacts of Functional Status at Both 1 Week After Admission and Discharge on Prognosis After Discharge
A total of 160 patients survived and were discharged. Among these patients, prognostic data were not available for 22 patients, and 44 patients experienced adverse events within 1 year after discharge. Six patients died due to cardiovascular diseases, 10 patients died due to non-cardiovascular causes, and 28 patients were re-hospitalized due to HF. We compared the event-free survival curves between patients who achieved functional recovery at discharge and those who did not, as shown in Figure 3A. We also compared those who attained early functional recovery with those who did not (Figure 3B). Patients who did not achieve functional recovery, defined as a BI <70 vs. BI ≥70 at discharge, had a significantly worse prognosis than those who did (log-rank P<0.001). Similarly, patients without early functional recovery, indicated by a BI <50 vs. BI ≥50 at 1 week after admission, also had a significantly worse prognosis compared with those with early recovery (log-rank P=0.044).
Figure 3.
(A) Comparison of event-free survival between patients with a Barthel Index (BI) ≥70 and those without at discharge. We compared the Kaplan–Meier event-free survival curves between patients who achieved functional recovery at discharge and those who did not. Patients who did not achieve functional recovery, defined as a BI score of 70 at discharge, had a significantly worse prognosis than those who did (log-rank P<0.001). (B) Comparison of event-free survival between patients with BI ≥50 and those without 1 week after admission. We compared the Kaplan–Meier event-free survival curves between patients who attained early functional recovery and those who did not. Patients without early functional recovery, indicated by a BI <50 vs. BI ≥50 at 1 week after admission, also had a significantly worse prognosis compared with those with early recovery (log-rank P=0.044).
Discussion
The present study revealed 4 significant findings regarding the differences in clinical backgrounds between patients who achieved functional recovery at discharge and those who did not. First, compared with patients who achieved functional recovery at discharge, those who did not were older, more frequently had concomitant dementia, and showed significantly lower albumin levels; they also showed an extended period of bed rest. Second, patients who recovered showed a significant increase in BI in the first week after admission and maintained this improvement thereafter, compared with those who did not recover. Third, the multivariable logistic regression analysis demonstrated that higher age, concomitant dementia, and a BI <50 at 1 week after admission were significantly associated with inadequate functional recovery at discharge. Last, patients who achieved functional recovery (BI ≥70) at discharge had a better prognosis after discharge than those who did not. Similarly, achieving early functional recovery, indicated by a BI score ≥50 at 1 week after admission, is associated with a better prognosis after discharge.
Recent reports suggest that physical frailty is strongly linked to a poor prognosis in HF.6,7 The BI is widely used as an assessment tool for physical frailty, based on a patient’s ability to perform basic daily activities, and is suitable for monitoring functional status in a clinical setting, especially for older HF patients, due to its repeatability and high reliability in inter-rater and test-retest assessments.18–20 Katano et al. demonstrated that, after adjusting for established prognostic indicators, a BI of <85 in older patients with HF (mean age 78 years) at discharge was linked to an increased risk of all-cause mortality following discharge.11 Additionally, Uemura et al. also demonstrated that low BI at discharge and decreased BI during hospitalization were related to poor outcomes after discharge in patients who were hospitalized due to ADHF.12 Consistently, in our study population, patients who did not achieve functional recovery, defined as a BI <70 vs. BI ≥70 at discharge, experienced more cardiovascular death or rehospitalization for HF after discharge compared with those who achieved functional recovery. An essential issue is how to maintain the functional status of older patients with ADHF during hospitalization for HF. We found significant associations between inadequate recovery and factors such as advanced age, the presence of concurrent dementia, and insufficient functional recovery at 1 week after admission. These factors could help risk-stratify functional recovery in older patients with HF. Anemia, concomitant dementia, poor nutrition, and increased inflammation have been reported to be significantly associated with low functional status and poor prognosis in older HF patients.21–25 In addition, in the nationwide multicenter registry for the investigation of the incidence of hospitalization-associated disability, defined as at least 5 points decrease in BI compared with that before admission, in the older (mean age 83.0 years) HF population in Japan, the patients who had a hospitalization-associated disability and showed lower BI scores at discharge more frequently had concomitant dementia assessed using some dementia scale compared with those without the disability.26 Consistently, in the present study, concomitant dementia and low albumin levels, which indicate poor nutrition and nutritional risk,27,28 showed significant associations with inadequate functional recovery at discharge for older HF patients. Regarding improvement in physical function during hospitalization, prolonged bed rest and insufficient improvement in BI during the first week of hospitalization (BI <50) were associated with functional recovery at discharge. Furthermore, after adjusting for aging, concomitant dementia, and low albumin levels in the multivariable model, inadequate functional recovery of BI <50 at 1 week after admission was significantly associated with low functional status at discharge. This finding means that early in-hospital assessment of physical function predicts functional recovery at discharge. Of note, the BI scores obtained at 1 week after admission have not previously been reported to be associated with functional recovery at discharge. Furthermore, not achieving early functional recovery, indicated by a BI <50 vs. BI ≥50 at 1 week after admission, is also associated with a worse prognosis after discharge. Early in-hospital assessment of functional status can identify high-risk patients who have insufficient functional recovery at discharge, resulting in a poor prognosis. This means that, similar to functional recovery at discharge, early functional recovery within the first week of hospitalization for ADHF could be an essential treatment goal linked to improved prognosis after discharge during early hospitalization for older HF patients. Impaired physical functions concomitant with HF lead to the progression of physical frailty by promoting further decline in motor function, associated with poor prognosis in older patients.29,30 Achieving functional recovery early may lead to sufficient recovery at discharge, preventing worsening HF. Kawamura et al. demonstrated that early achievement of walkability after cardiac surgery was associated with good outcomes and lowered the risk of hospitalization for HF.31 In the present study, patients who did not achieve functional recovery at discharge had significantly longer periods of bed rest and were started on bedside rehabilitation later than those who did. High-risk older patients hospitalized for HF who were identified using an early BI assessment may require intensive cardiac rehabilitation. Multiple studies have documented the beneficial effects of comprehensive cardiac rehabilitation on the physical condition of HF patients.18,32 As a result, cardiac rehabilitation programs are anticipated to enhance physical function in patients, even during the early phase of hospitalization for HF. This program is critical during early hospitalization and is implemented through a multidisciplinary approach. However, patients with a BI <70 at discharge had longer periods of bed rest and a tendency towards delayed initiation of bedside rehabilitation. Although no significant difference in cardiac rehabilitation completion rates was observed between groups, these findings suggest that factors related to rehabilitation timing and early mobilization may be associated with functional recovery. Because this was an observational study, the causal impact of rehabilitation intensity or timing cannot be definitively determined. Therefore, future prospective studies are warranted to clarify the role of rehabilitation strategies and to identify the key BI components associated with functional recovery and post-discharge prognosis in older ADHF patients.
Study Limitations
This study has several limitations. First, this study was conducted as a single-center, retrospective analysis, and the number of study patients was small. Greater caution is necessary regarding bias in patient selection, and a prospective observational study involving a larger number of patients is needed to strengthen our conclusions. Second, dementia was diagnosed and treated in 24.4% of the patients in the study. Concomitant dementia is known to be associated with a decrease in physical function.26,33 However, in this study, dementia was identified based on prior specialist diagnosis or use of anti-dementia medications, rather than standardized cognitive assessments. This approach may have resulted in misclassification, particularly in patients with undiagnosed or mild cognitive impairment, and may have affected the accuracy of the observed association with functional recovery. Future prospective studies incorporating validated cognitive scales, such as the Mini-Mental State Examination or Montreal Cognitive Assessment, are needed to better clarify this relationship. Third, although previous studies have used higher BI cut-offs, such as 80 or 85, to define functional independence, and have demonstrated associations between discharge BI and long-term prognosis, we adopted the lower cut-off of a BI of 70 based on clinical considerations. Specifically, a BI of 70 was prespecified as representing the minimal level of functional independence sufficient to maintain home living in older patients hospitalized with ADHF, even if assistance is required for more demanding activities. Consistently, this cut-off also stratified the post-discharge prognosis in our cohort. However, the optimal BI threshold for predicting prognosis and functional recovery in older patients with ADHF remains uncertain and should be validated in future studies. Fourth, the BI was not assessed at admission due to strict bed rest requirements in a substantial proportion of patients, and BI assessment during the early acute phase (e.g., 3 days after admission) was not available due to the retrospective study design. As a result, we were unable to evaluate the relationship between the BI at admission and functional recovery at discharge or to determine the earliest time point at which BI assessment may predict discharge functional status. Last, a detailed analysis of individual BI items was not performed. Such analyses may help identify specific ADL components associated with functional recovery and prognosis, as well as the clinical importance suggested by a BI cut-off of 50 for predicting functional recovery (BI ≥70) at discharge 1 week after admission, and should be explored in future prospective studies.
Conclusions
In older patients hospitalized for ADHF who maintained pre-admission functional status, early impairment in functional recovery during hospitalization predicted inadequate functional recovery at discharge and was also associated with worse post-discharge outcomes, suggesting that early BI assessment may help identify patients at risk of persistent functional decline.
Disclosures
Y.S. is a member of Circulation Reports’ Editorial Team. The other authors declare that there are no conflicts of interest.
IRB Information
The present study was approved by the Institutional Review Boards and Ethics Committees of Nagoya City University Graduate School of Medical Sciences, Japan (reference no. 60-23-0167).
Supplementary Files
Supplementary Figure.
Data Availability
The deidentified participant data will not be shared.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplementary Figure.
Data Availability Statement
The deidentified participant data will not be shared.