Assisted Early Mobility for Hospitalized Older Veterans STRIDE Assisted Early Mobility for Hospitalized Older Veterans S. Nicole Hastings, MD, MHS Durham VAMC Geriatrics Research Education and Clinical Center (GRECC), Center for Health Services Research in Primary Care and Ambulatory Care Service Duke University, Department of Medicine, Division of Geriatrics Duke Center for the Study of Aging and Human Development

Disclosure Statement This work was supported by: VA Office of Geriatrics and Extended Care (Non-Institutional Care Pilot 558-3) VA HSR&D (RCD 06-019) The investigators retained full independence in the conduct of this research.

Outline Describe STRIDE program Report results of initial evaluation Program goals Eligibility criteria Staff roles Report results of initial evaluation Baseline patient characteristics Outcomes: hospital length of stay, inpatient falls, discharge destination, and ED visits and readmissions within 30 days of discharge

Clinical Problem Hospitalized older adults spend only 3% of their time standing or walking <5% have physician orders for bed rest Immobility during hospitalization has many negative physical effects: loss of muscle mass, deconditioning, overall weakness Poor physical function associated with adverse outcomes falls, delirium, longer hospital stays, higher rates of discharge to skilled nursing facilities and readmission Covinsky JAMA 2011 306(16); Kommuri Arch Med Res 2010 41(5); Zisberg JAGS 2011 59(2); Brown JAGS 2009 57(9); Murphy Arch Int Med 2011 171(3)

Objectives To optimize the physical function of older Veterans by increasing the amount of time spent walking during their hospitalization Key program features Proactive, no baseline functional deficits required Early assessment, ideally within 24 hours of admission Supervised walking, up to 20 minutes daily until discharge

Targeted gait and balance assessment STRIDE Patient Flow TARGET POPULATION Patients > 60 admitted to medical service referred by treating physician NOT ELIGIBLE Chest pain or angina Admitted from nursing home New neurological deficit Surgery planned Bedrest order Unable to follow 1 step command Non-ambulatory Targeted gait and balance assessment Performed by Physical Therapist NO YES Safe for STRIDE? Usual Care STRIDE Program 1-2 walks daily for duration of hospitalization supervised by Recreation Therapy Assistant

STRIDE Staff Roles Physical Therapist Screens consults Performs baseline balance and gait assessment Recommends assistive devices and/or gait belt if needed Identifies activity goals with patients

STRIDE Staff Roles Recreation Therapy Assistant Works with Nursing to plan timing of daily walks Supervises walks for safety Reviews activity goals Provides motivation and encouragement

STRIDE Baseline Characteristics STRIDE participants, n=66 Demographics Age, mean (SD), y 74. 2 (9) Sex, % male 98.5 Race, % black 31.8 By yourself, that is without help from another person or special equipment, do you have any difficulty walking for a quarter of a mile, that is about 2 or 3 blocks? At least some difficulty or could not do Assistive device – canes 58% Anxious or worried you might fall, past 12 months Ostir, Arch Int Med 2012 – community dwelling, admitted to ACE unit, no confusion, no “tethers”, the mean (SD) gait speed for patients who completed the gait speed walk was 0.53 (0.25) m/s. Blankenburg, Clin Respir J. 2012 Jul 23. – 6 min walk distance in elderly COPD patients 97 meters at admission (little less than double the 58 meters we observed for 2 min test); heart failure patients, the median distance walked on the 6MWT was 213 m (J Card Fail. 2009 Mar;15(2):130-5. Epub 2008 Dec 5). ME Tinetti Performance-oriented assessment of mobility problems in elderly patients

STRIDE Baseline Characteristics Functional status of STRIDE participants, n=66 Self-Report Difficulty walking/ 2-3 blocks,* % yes 65 Assistive device, % yes 48 Falls in past 3 months, % yes 39 Performance Measures 2 minute walk distance (f), mean (SD) 186.5 (92) Gait speed (m/s), mean (SD) 0.48 (0.2) Balance score,† mean (SD) 11.8 (3) By yourself, that is without help from another person or special equipment, do you have any difficulty walking for a quarter of a mile, that is about 2 or 3 blocks? At least some difficulty or could not do Assistive device – canes 58% Anxious or worried you might fall, past 12 months Ostir, Arch Int Med 2012 – community dwelling, admitted to ACE unit, no confusion, no “tethers”, the mean (SD) gait speed for patients who completed the gait speed walk was 0.53 (0.25) m/s. Blankenburg, Clin Respir J. 2012 Jul 23. – 6 min walk distance in elderly COPD patients 97 meters at admission (little less than double the 58 meters we observed for 2 min test); heart failure patients, the median distance walked on the 6MWT was 213 m (J Card Fail. 2009 Mar;15(2):130-5. Epub 2008 Dec 5). ME Tinetti Performance-oriented assessment of mobility problems in elderly patients * At least “some” difficulty or can’t do it † Balance subscale of Performance Oriented Mobility Assessment, max score 16

STRIDE Comparison Group STRIDE, n=66 Wait List, n=28 Age, mean (SD), y 74. 2 (9) 73.3 (10) Sex, % male 98.5 100 Race, % black 31.8 21.4 Wait List – referred by provider and eligible but program at capacity P=0.3

STRIDE Comparison Group STRIDE, n=66 Wait List, n=28 Calculated Probability of Readmission Risk Score, % 21.6 19.7 Developed by VA Inpatient Evaluation Center, VHA Office of Quality and Safety Calculates risk of 30 day readmission based on risk factors including: patient demographics, hospitalization information, previous admissions, medication, lab values and primary or comorbid diagnoses P=0.3

STRIDE Outcomes - Length of Stay P=0.1 P=0.09 P =0.1 for LOS and 0.09 for consult to discharge for Wilcoxon P=0.1 for LOS and 0.2 for consult to discharge for t-test (pooled) 18% of consults received when patient was in “observation” status; majority of these converted to “regular” admission, but obs time not calculated in official LOS measures

STRIDE Outcomes STRIDE, n=66 Wait List, n=28 Inpatient Falls 1 Discharge to SNF* 5 (7.6%) 7 (25%) 30-day ED visits 21.2% 21.4% 30-day readmissions 15.1% 14.3% Discharge to SNF – Fisher’s Exact test P=0.04 * P=0.04

Limitations Comparison group Unclear mechanism Contemporaneous and similar demographically Small and non-randomized Unclear mechanism Impact on physical function? Or changes in patient confidence and/or provider behavior?

STRIDE Summary STRIDE is safe and well-tolerated by older Veterans hospitalized for medical illness. Program participants had reduced length of stay, fewer SNF admissions for short-term rehab, and no increase in post-discharge acute utilization. STRIDE is a promising interdisciplinary approach to promoting mobility and improving outcomes among hospitalized older adults.

STRIDE Next Steps Expand program evaluation STRIDE@HOME (PI Peterson) Program participants to date, n=274 Patient and provider feedback STRIDE@HOME (PI Peterson) funded by Office of Geriatrics and Extended Care (558-4) Future research questions Optimal “dose” of walking, in terms of total minutes, number of sessions/day, distance. Understand effects of walking program/ disentangle reasons for reduced LOS: physiologic versus impact on providers

STRIDE Physical Therapist Acknowledgements Funder: VA Office of Geriatrics and Extended Care STRIDE Team Dennis Bongiorni Helen Hoenig Bill Jackson Kendra Monden Miriam Morey Megan Pearson Rick Sloane Lauri Jugan, MPT STRIDE Physical Therapist Ural Kincaid, RTA Program Assistant

STRIDE Daily Walks Day #1 Walks Of those with walk completed: Minutes walked, mean (SD) 10 (4.5) Distance walked, (f) mean (SD), median 476.2 (446) , 317 Perceived exertion (0-10), mean (SD) 3.9 (2.4) Energy level after walk, % improved 71 How you feel overall after walk, % better 90 Falls, % How did today’s walk affect how you feel? Feel better, worse, same How important is this walking program to helping you recover

Contact Information S. Nicole Hastings, MD, MHS Email: hasti003@mc.duke.edu Phone: 919.630.3825