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Age and ageing  2008;37(3):288-293.
Early studies reported controversial findings on association of Apolipoprotein E (APOE) polymorphism with disability.
To analyze sex-specific associations of APOE genotypes with impairments in (Instrumental) Activities of Daily Living [(I)ADL] and mortality.
Population-based 1999 National Long Term Care Survey of the U.S. older (65+) individuals.
Genetic data are available for 1805 individuals.
Each of six genotypes of three common alleles of the APOE locus (ε2, ε3, and ε4) was tested on the association with a disability index or mortality.
APOE ε3/3 genotype significantly decreases odds ratio (OR) for IADL disability in males (OR=0.48; 95% Confidence Interval [CI]: 0.31–0.76) while it exhibits no association in females. The OR for ADL disability is 0.19 (CI: 0.04–0.99) for ε4/4 female carriers. The ε2/3 genotype increases the chances of IADL disability for males (OR=2.33; CI: 1.28–4.25). No significant association between APOE polymorphism and mortality was found. A surprising observation was that ε4/4 female carriers have a 5.3 times lower chance of having ADL disability than do non-ε4/4-carriers.
Associations of the APOE polymorphism with disability and lack of association with mortality supports the view that APOE gene actions may be more significant as modulators of frailty than of longevity.
PMCID: PMC2710764  PMID: 18250093
Apolipoprotein E; disability; sex differences; elderly
2.  Association of Chronic Diseases and Impairments with Disability in Older Adults: A Decade of Change? 
Medical Care  2012;50(6):501-507.
Little is known about how the relationship between chronic disease, impairment, and disability has changed over time among older adults.
To examine how the associations of chronic disease and impairment with specific disability have changed over time.
Research Design
Repeated cross-sectional analysis, followed by examining the collated sample using time interaction variables, of 3 recent waves of the Health and Retirement Study.
10390, 10621 and 10557 community dwelling adults aged 65+ in 1998, 2004, 2008
Survey-based history of chronic diseases including hypertension, heart disease, heart failure, stroke, diabetes, cancer, chronic lung disease and arthritis; impairments, including cognition, vision and hearing; and disability, including mobility, complex activities of daily living (ADL) and self-care ADL.
Over time, the relationship of chronic diseases and impairments with disability were largely unchanged; however, the association between hypertension and complex ADL disability weakened from 1998, to 2004 and 2008 (OR=1.24, 99% CI, 1.06–1.46; OR=1.07, 99% CI, 0.90–1.27; OR=1.00, 99%CI, 0.83–1.19 respectively), as it did for hypertension and self-care disability (OR=1.32, 99%CI, 1.13–1.54; OR=0.97, 99% CI, 0.82–1.14; OR=0.99, 99%CI, 0.83–1.17). The association between diabetes and self-care disability strengthened from 1998 to 2004 and 2008 (OR=1.21, 99% CI, 1.01–1.46; OR=1.37, 99% CI, 1.15–1.64; OR=1.52, 99% CI, 1.29–1.79), as it also did for lung disease and self-care disability (OR=1.64, 99%CI, 1.33–2.03; OR=1.63, 99% CI, 1.32–2.01; OR=2.11, 99% CI, 1.73–2.57).
While relationships between diseases, impairments and disability were largely unchanged, disability became less associated with hypertension and more with diabetes and lung disease.
PMCID: PMC3353149  PMID: 22584885
chronic disease; impairment; disability; prevalence trends
3.  Disability in activities of daily living, depression, and quality of life among older medical ICU survivors: a prospective cohort study 
Accurate measurement of quality of life in older ICU survivors is difficult but critical for understanding the long-term impact of our treatments. Activities of daily living (ADLs) are important components of functional status and more easily measured than quality of life (QOL). We sought to determine the cross-sectional associations between disability in ADLs and QOL as measured by version one of the Short Form 12-item Health Survey (SF-12) at both one month and one year post-ICU discharge.
Data was prospectively collected on 309 patients over age 60 admitted to the Yale-New Haven Hospital Medical ICU between 2002 and 2004. Among survivors an assessment of ADL's and QOL was performed at one month and one-year post-ICU discharge. The SF-12 was scored using the version one norm based scoring with 1990 population norms. Multivariable regression was used to adjust the association between ADLs and QOL for important covariates.
Our analysis of SF-12 data from 110 patients at one month post-ICU discharge showed that depression and ADL disability were associated with decreased QOL. Our model accounted for 17% of variability in SF12 physical scores (PCS) and 20% of variability in SF12 mental scores (MCS). The mean PCS of 37 was significantly lower than the population mean whereas the mean MCS score of 51 was similar to the population mean. At one year mean PCS scores improved and ADL disability was no longer significantly associated with QOL. Mortality was 17% (53 patients) at ICU discharge, 26% (79 patients) at hospital discharge, 33% (105 patients) at one month post ICU admission, and was 45% (138 patients) at one year post ICU discharge.
In our population of older ICU survivors, disability in ADLs was associated with reduced QOL as measured by the SF-12 at one month but not at one year. Although better markers of QOL in ICU survivors are needed, ADLs are a readily observable outcome. In the meantime, clinicians must try to offer realistic estimates of prognosis based on available data and resources are needed to assist ICU survivors with impaired ADLs who wish to maintain their independence. More aggressive diagnosis and treatment of depression in this population should also be explored as an intervention to improve quality of life.
PMCID: PMC3041645  PMID: 21294911
4.  Clinically diagnosed infections predict disability in activities of daily living among the oldest-old in the general population: the Leiden 85-plus Study 
Age and Ageing  2013;42(4):482-488.
Background: ageing is frequently accompanied by a higher incidence of infections and an increase in disability in activities of daily living (ADL).
Objective: this study examines whether clinical infections [urinary tract infections (UTI) and lower respiratory tract infections (LRTI)] predict an increase in ADL disability, stratified for the presence of ADL disability at baseline (age 86 years).
Design: the Leiden 85-plus Study. A population-based prospective follow-up study.
Setting: general population.
Participants: a total of 154 men and 319 women aged 86 years.
Methods: information on clinical infections was obtained from the medical records. ADL disability was determined at baseline and annually thereafter during 4 years of follow-up, using the 9 ADL items of the Groningen Activity Restriction Scale.
Results: in 86-year-old participants with ADL disability, there were no differences in ADL increase between participants with and without an infection (−0.32 points extra per year; P = 0.230). However, participants without ADL disability at age 86 years (n = 194; 41%) had an accelerated increase in ADL disability of 1.07 point extra per year (P < 0.001). For UTIs, this was 1.25 points per year (P < 0.001) and for LRTIs 0.70 points per year (P = 0.041). In this group, an infection between age 85 and 86 years was associated with a higher risk to develop ADL disability from age 86 onwards [HR: 1.63 (95% CI: 1.04–2.55)].
Conclusions: among the oldest-old in the general population, clinically diagnosed infections are predictive for the development of ADL disability in persons without ADL disability. No such association was found for persons with ADL disability.
PMCID: PMC3684111  PMID: 23482352
ADL disability; infections; oldest-old; general population; older people
5.  Recovery in Activities of Daily Living Among Older Adults Following Hospitalization for Acute Medical Illness 
To describe functional outcomes in the year following discharge for elders discharged from the hospital after an acute medical illness with a new or additional disability in their basic self-care activities of daily living(ADL)(compared to their preadmission baseline two weeks before admission), compared to elders discharged with baseline ADL function, and identify predictors of failure to recover to baseline function one year after discharge.
Observational Study
Tertiary care hospital, Community teaching hospital
Older(≥70 years) patients non-electively admitted to general medical services(1993-1998).
Number of ADL disabilities 1,3,6,&12 months after discharge compared to pre-admission baseline. Outcomes were death, sustained decline in ADL function, and recovery to baseline ADL function at each timepoint.
By 12 months after discharge, among those discharged with new or additional ADL disability, 41.3% died, 28.6% were alive but had not recovered to baseline function, and 30.1% were at their baseline function. Among those discharged with baseline function, 17.8% died, 15.2% were alive but with worse than baseline function, and 67% were at their baseline function(p<.001). Among those discharged with new or additional ADL disability, the presence or absence of recovery by one month was associated with long-term outcomes. Age, cardiovascular disease, dementia, cancer, low albumin, and greater number of dependencies in IADL independently predict failure to recover.
Among elders discharged with new or additional disability in ADL following hospitalization for medical illness, prognosis for functional recovery is poor. Rehabilitation interventions of longer duration and timing than current reimbursement allows, caregiver support, and palliative care should be evaluated.
PMCID: PMC2717728  PMID: 19093915
hospitalization; functional decline; recovery
6.  Pain as a Risk Factor for Disability or Death 
To determine whether pain predicts future activity of daily living (ADL) disability or death in individuals aged 60 years and above.
Prospective cohort study
The 1998 to 2008 Health and Retirement Study (HRS), a nationally-representative study of older community-living individuals.
Twelve thousand six hundred and thirty-one participants in the 1998 HRS aged 60 years and older who did not need help in any activity of daily living (ADL).
Participants reporting that they were troubled by moderate or severe pain most of the time were defined as having significant pain. Our primary outcome was time to development of ADL disability or death over 10 years, assessed in 5 successive 2 year intervals. ADL disability was defined as needing help performing any ADL: bathing, dressing, transferring, toileting, eating, or walking across a room. We used a discrete hazards survival model to examine the relationship between pain and incident disability over each two year interval using only participants who started the interval with no ADL disability. We adjusted for several potential confounders at the start of each interval: demographic factors, 7 chronic health conditions, and functional limitations (ADL difficulty, and difficulty with 5 measures of mobility).
At baseline, 2,283 (18%) subjects had significant pain. Subjects with pain were more likely (all p<0.001) to be female (65% vs. 54%), have ADL difficulty (eg. transferring 12% vs. 2%, toileting 11% vs. 2%), have difficulty walking several blocks (60% vs. 21%), and have difficulty climbing one flight of stairs (40% vs. 12%). Over 10 years, subjects with pain were more likely to develop ADL disability or death (58% vs43%, unadjusted HR 1.67, 95% confidence interval (1.57 to 1.79)). However, after adjustment for confounders, participants with pain were not at increased risk for ADL disability or death (HR 0.98 (0.91 to 1.07)). The difference between the unadjusted and adjusted results was almost entirely explained by adjustment for functional status.
While there are strong cross-sectional relationships between pain and functional limitations, individuals with pain are not at higher risk for subsequent disability or death, after accounting for functional limitations. Like many geriatric syndromes, pain and disability may represent interrelated phenomena that occur simultaneously and require unified treatment paradigms.
PMCID: PMC3628294  PMID: 23521614
pain; functional limitations; activities of daily living; disability; quality of life
7.  Evaluating the Utility of Existing Patient-Reported Outcome Scales in Novel Patient Populations with Pancreatic Cancer, Lung Cancer, and Myeloproliferative Neoplasms Using Medicare Current Beneficiary Survey Data 
The Patient  2013;6(3):189-200.
While there are validated patient-reported outcomes (PRO) instruments for use in specific cancer populations, no validated general instruments exist for use in conditions common to multiple cancers, such as muscle wasting and consequent physical disability. The Medicare Current Beneficiary Survey (MCBS), a survey in a nationally representative sample of Medicare beneficiaries, includes items from three well known scales with general applicability to cancer patients: Katz activities of daily living (ADL), Rosow–Breslau instrumental ADL (IADL), and a subset of physical performance items from the Nagi scale.
This study evaluated properties of the Katz ADL, Rosow–Breslau IADL, and a subset of the Nagi scale in patients with pancreatic cancer, lung cancer, and myeloproliferative neoplasms (MPN) using data from MCBS linked with Medicare claims in order to understand the potential utility of the three scales in these populations; understanding patient-perceived significance was not in scope.
The study cohorts included Medicare beneficiaries aged ≥65 years as of 1 January of the year of their first cancer diagnosis with one or more health assessments in a community setting in the MCBS Access to Care data from 1991 to 2009. Beneficiaries had at least two diagnoses in de-identified Medicare claims data linked to the MCBS for one of the following cancers: pancreatic, lung, or MPN. The Katz ADL, Rosow–Breslau IADL, and Nagi scales were calculated to assess physical functioning over time from cancer diagnosis. Psychometric properties for each scale in each cohort were evaluated by testing for internal consistency, test–retest reliability, and responsiveness by comparing differences in mean scale scores over time as cancer progresses, and differences in mean scale scores before and after hospitalization (for lung cancer cohort).
The study cohorts included 90 patients with pancreatic cancer, 863 with lung cancer, and 135 with MPN. Among each cancer cohort, the Katz ADL, Rosow–Breslau IADL, and Nagi scales had acceptable internal consistency (Cronbach’s alpha generally between 0.70 and 0.90) and test–retest reliability for consecutive surveys before diagnosis and consecutive surveys after diagnosis (when patients’ functioning was more stable). Compared with mean scale scores at the survey 1–2 years before cancer diagnosis (baseline), mean scale scores at the first survey after cancer diagnosis were significantly higher (P < 0.05), indicating worsening, for Katz ADL, Rosow–Breslau IADL, and Nagi scales (items scored 0–1) (0.54 vs. 1.45, 1.15 vs. 2.20, and 2.29 vs. 3.08, respectively, for pancreatic cancer; 0.73 vs. 1.24, 1.29 vs. 2.01, and 2.41 vs. 2.85 for lung cancer; and 0.44 vs. 0.86, 0.87 vs. 1.36, and 1.87 vs. 2.32 for MPN). Among lung cancer patients, scale scores increased significantly following a hospitalization, suggesting a worsening of functional status.
The Katz ADL, Rosow–Breslau IADL, and Nagi scales collected in the MCBS demonstrate acceptable internal consistency and test–retest reliability among patients with pancreatic cancer, lung cancer, and MPN, and are consistent with clinical worsening following diagnosis or hospitalization. These results suggest that using retrospective data may allow researchers to conduct preliminary assessments of existing PRO instruments in new populations of interest and generate useful exploratory disease information before embarking on de novo PRO development.
PMCID: PMC3751268  PMID: 23828691
8.  Risk factors for disability in older persons over 3-year follow-up 
Age and Ageing  2009;39(1):92-98.
Background: the identification of modifiable risk factors for preventing disability in older individuals is essential for planning preventive strategies.
Purpose: to identify cross-sectional correlates of disability and risk factors for the development activities of daily living (ADL) and instrumental ADL (IADL) disability in community-dwelling older adults.
Methods: the study population consisted of 897 subjects aged 65–102 years from the InCHIANTI study, a population-based cohort in Tuscany (Italy). Factors potentially associated with high risk of disability were measured at baseline (1998–2000), and disability in ADLs and IADLs were assessed both at baseline and at the 3-year follow-up (2001–03).
Results: the baseline prevalence of ADL disability and IADL disability were, respectively, 5.5% (49/897) and 22.2% (199/897). Of 848 participants free of ADL disability at baseline, 72 developed ADL disability and 25 of the 49 who were already disabled had a worsening in ADL disability over a 3-year follow-up. Of 698 participants without IADL disability at baseline, 100 developed IADL disability and 104 of the 199 who already had IADL disability had a worsening disability in IADL over 3 years. In a fully adjusted model, high level of physical activity compared to sedentary state was significantly associated with lower incidence rates of both ADL and IADL disability at the 3-year follow-up visit (odds ratio (OR): 0.30; 95% confidence intervals (CI) 0.12–0.76 for ADL disability and OR: 0.18; 95% CI 0.09–0.36 for IADL disability). After adjusting for multiple confounders, higher energy intake (OR for difference in 100 kcal/day: 1.09; 95% CI 1.02–1.15) and hypertension (OR: 1.91; 95% CI 1.06–3.43) were significant risk factors for incident or worsening ADL disability.
Conclusions: higher level of physical activity and lower energy intake may be protective against the development in ADL and IADL disability in older persons.
PMCID: PMC2800253  PMID: 19933449
prevention; disability; physical activity; energy; ageing; elderly
9.  Hospital Readmission Among Older Adults Who Return Home With Unmet Need for ADL Disability 
The Gerontologist  2012;53(3):454-461.
Purpose: This study determined whether returning to the community from a recent hospitalization with unmet activities of daily living (ADL) need was associated with probability of readmission. Methods: A total of 584 respondents to the 1994, 1999, and/or 2004 National Long-Term Care Surveys (NLTCS) who were hospitalized within 90 days prior to the interview and reported ADL disability at the time of the interview were considered for analysis. Medicare claims linked to the NLTCS provided information about hospital episodes, so those enrolled in Health Maintenance Organizations or Veterans Affairs Medical Centers were not included (n = 62), resulting in a total sample size of 522. ADL disability was defined as needing human help or equipment to complete the task. Unmet ADL need was defined as receiving inadequate or no help for one or more ADL disabilities. Disability that began within 90 days of the interview was considered new disability. Results: After adjusting for demographic, health, and functioning characteristics, unmet ADL need was associated with increased risk for hospital readmission (HR: 1.37, 95% CI: 1.03–1.82). Risk of readmission was greater for those with unmet need for new disabilities than those with unmet need for disabilities that were present before the index hospitalization (HR: 1.66, 95% CI: 1.01–2.73). Implications: Many older patients are discharged from the hospital with ADL disability. Those who report unmet need for new ADL disabilities after they return home from the hospital are particularly vulnerable to readmission. Patients' functional needs after discharge should be carefully evaluated and addressed.
PMCID: PMC3635854  PMID: 22859438
Activities of daily living; Insufficient help
10.  Association of upper gastrointestinal symptoms with functional and clinical charateristics in elderly 
AIM: To evaluate the prevalence of upper gastrointestinal symptoms and their association with clinical and functional characteristics in elderly outpatients.
METHODS: The study involved 3238 outpatients ≥ 60 years consecutively enrolled by 107 general practitioners. Information on social, behavioral and demographic characteristics, function in the activities of daily living (ADL), co-morbidities and drug use were collected by a structured interview. Upper gastrointestinal symptom data were collected by the 15-items upper gastro-intestinal symptom questionnaire for the elderly, a validated diagnostic tool which includes the following five symptom clusters: (1) abdominal pain syndrome; (2) reflux syndrome; (3) indigestion syndrome; (4) bleeding; and (5) non-specific symptoms. Presence and severity of gastrointestinal symptoms were analyzed through a logistic regression model.
RESULTS: 3100 subjects were included in the final analysis. The overall prevalence of upper gastrointestinal symptoms was 43.0%, i.e. cluster (1) 13.9%, (2) 21.9%, (3) 30.2%, (4) 1.2%, and (5) 4.5%. Upper gastrointestinal symptoms were more frequently reported by females (P < 0.0001), with high number of co-morbidities (P < 0.0001), who were taking higher number of drugs (P < 0.0001) and needed assistance in the ADL. Logistic regression analysis demonstrated that female sex (OR = 1.39, 95% CI: 1.17-1.64), disability in the ADL (OR = 1.47, 95% CI: 1.12-1.93), smoking habit (OR = 1.29, 95% CI: 1.00-1.65), and body mass index (OR = 1.06, 95% CI: 1.04-1.08), as well as the presence of upper (OR = 3.01, 95% CI: 2.52-3.60) and lower gastroenterological diseases (OR = 2.25, 95%CI: 1.70-2.97), psychiatric (OR = 1.60, 95% CI: 1.28-2.01) and respiratory diseases (OR = 1.25, 95% CI: 1.01-1.54) were significantly associated with the presence of upper gastrointestinal symptoms.
CONCLUSION: Functional and clinical characteristics are associated with upper gastrointestinal symptoms. A multidimensional comprehensive evaluation may be useful when approaching upper gastrointestinal symptoms in older subjects.
PMCID: PMC3132253  PMID: 21799648
Upper gastrointestinal symptoms; Elderly; Upper gastro-intestinal symptom questionnaire for the elderly; Gastroesophageal reflux disease; Disability
11.  Benzodiazepine Use and Physical Disability in Community-Dwelling Older Adults 
To determine whether benzodiazepine use is associated with incident disability in mobility and activities of daily living (ADLs) in older individuals.
A prospective cohort study.
Four sites of the Established Populations for Epidemiologic Studies of the Elderly.
This study included 9,093 subjects (aged ≥65) who were not disabled in mobility or ADLs at baseline.
Mobility disability was defined as inability to walk half a mile or climb one flight of stairs. ADL disability was defined as inability to perform one or more basic ADLs (bathing, eating, dressing, transferring from a bed to a chair, using the toilet, or walking across a small room). Trained interviewers assessed outcomes annually.
At baseline, 5.5% of subjects reported benzodiazepine use. In multivariable models, benzodiazepine users were 1.23 times as likely as nonusers (95% confidence interval (CI) = 1.09–1.39) to develop mobility disability and 1.28 times as likely (95% CI = 1.09–1.52) to develop ADL disability. Risk for incident mobility was increased with short- (hazard ratio (HR) = 1.27, 95% CI = 1.08–1.50) and long-acting benzodiazepines (HR = 1.20, 95% CI = 1.03–1.39) and no use. Risk for ADL disability was greater with short- (HR = 1.58, 95% CI = 1.25–2.01) but not long-acting (HR = 1.11, 95% CI = 0.89–1.39) agents than for no use.
Older adults taking benzodiazepines have a greater risk for incident mobility and ADL disability. Use of short-acting agents does not appear to confer any safety benefits over long-acting agents.
PMCID: PMC2365497  PMID: 16460372
benzodiazepines; activities of daily living; disability; adverse drug event
12.  Dynamics of Functional Aging Based on Latent-class Trajectories of Activities of Daily Living 
Annals of epidemiology  2013;23(2):87-92.
This study sought to identify and characterize major patterns of functional aging based on activities of daily living (ADL).
754 community-living adults 70 years or older were followed monthly for ADLs, instrumental ADLs (IADLs), hospitalization and restricted activity over ten years. A generalized growth mixture model was used to identify trajectories of ADL disability across seven 18-month intervals. Cumulative burdens of disability and morbidity from different trajectories were examined using a generalized estimating equation Poisson model.
Five distinct trajectories emerged. The predominant trajectory maintained ADL independence, with membership probability being 61.6%. The remaining trajectories either stayed at low (1 or 2 ADLs, 13.6%) or high (3 or 4 ADLs, 7.0%) levels of disability or declined gradually towards low (11.2%) or high (6.5%) disability. The independent trajectory was associated with the lowest burdens of disability and morbidity and a decreasing time trend of restricted activity; whereas the high disability trajectory demonstrated opposite trends. About 31% of the cohort remained in the same trajectory throughout the follow-up period.
The course of functional aging is heterogeneous and dynamic. While most older adults maintain functional autonomy, some may experience persistent disability or progress towards severe disability with substantial morbidity.
PMCID: PMC3558979  PMID: 23305692
Latent class growth mixture model; functional aging; activities of daily living; hospitalizations; restricted activities
To determine the association between depression and functional recovery among community-living older persons who had a decline in function after an acute hospital admission.
Prospective cohort study.
General community in greater New Haven, Connecticut, from March 1998 to December 2008.
Seven-hundred fifty four persons, aged 70 years or older.
Hospitalization and disability in essential activities of daily living (ADLs) and mobility were assessed each month for up to 129 months, and depressive symptoms were assessed every 18 months using the Center for Epidemiologic Studies of Depression (CES-D) Scale. Functional recovery was defined as returning to the community within 6 months at or above the pre-hospital level of ADL function and mobility, respectively.
A decline in ADL function and mobility was observed following 42% and 41% of the hospitalizations, respectively. After controlling for several potential confounders, clinically significant depressive symptoms (CES-D ≥20) was associated with a lower likelihood of recovering mobility function (HR= 0.79; 95%CI 0.63, 0.98), but not ADL function (HR= 0.91; 95%CI 0.75, 1.10), within 6 months of hospitalization.
Following a disabling hospitalization among community-living older persons, those with pre-existing depression may be less likely to recover their pre-hospitalization level of mobility function, but not ADL function. Yet, the reasons remain to be elucidated.
PMCID: PMC3136548  PMID: 21668916
Depression; hospitalization; functional decline; recovery
14.  Association of Vitamin D Deficiency with Functional Disability and Chronic Diseases Among Veterans Entering a Nursing Home 
Nursing home residents are at high risk of vitamin D deficiency. There has been only one previous study about vitamin D status on admission to the nursing home, and limited data are available about associations with functional disability and chronic diseases.
Data were collected by retrospective chart review of electronic medical records and Minimum Data Set (MDS) for all veterans admitted to a VA nursing home in Honolulu, Hawai‘i, between January 2011 and June 2012. All veterans had a comprehensive geriatric assessment and measurement of serum 25-hydroxyvitamin D level within 7 days of admission. Females, hospice patients, vitamin D supplement users, and those transferred from other nursing homes were excluded, leaving a final analytic sample of 104 patients. Vitamin D deficiency was defined as serum 25-hydroxyvitamin D level <20 ng/mL. Baseline data collected included age, ethnicity, BMI, functional disability (mobility, bathing, dressing, toileting, continence, and feeding) and prevalent chronic diseases to study cross-sectional associations of vitamin D deficiency using logistic regression.
Prevalence of vitamin D deficiency on admission to the nursing home was 49.0% (51/104) among male veterans not taking supplements. The mean age was 70.6 years (range 35–95), with ethnicity as follows: 51 (49.0%) White, 34 (32.7%) Asian, and 6 (5.8%) Black. In multiple logistic regression models adjusted for age, ethnicity and BMI, vitamin D deficiency was significantly associated with number of ADL disabilities (OR = 1.36 for each increase in ADL disability, 95%CI = 1.03–1.78, P = .03) and prevalent diabetes (OR = 2.99, 95%CI = 1.12–7.99, P = .03). When all six ADL disabilities were entered separately into the multivariate logistic regression model instead of total number of ADL disabilities, only the disability in feeding (OR = 4.74, 95%CI = 0.97–23.23, P = .05) and prevalent diabetes (OR = 2.92, 95%CI = 1.03–8.24, P = .04) remained significant. There were no significant associations between vitamin D deficiency and prevalent hypertension, hypercholesterolemia, coronary artery disease, stroke, cancer, depression or dementia.
Almost half the male patients entering a nursing home in Hawai‘i had vitamin D deficiency. A high number of ADL disabilities, disability in feeding, and prevalent diabetes were independently associated with vitamin D deficiency. Future studies should focus on targeting these patients for screening and intervention with supplementation to possibly prevent adverse health outcomes of vitamin D deficiency.
PMCID: PMC3764550
15.  Comprehensive geriatric assessment predicts mortality and adverse outcomes in hospitalized older adults 
BMC Geriatrics  2014;14(1):129.
Comprehensive Geriatric Assessment (CGA) provides detailed information on clinical, functional and cognitive aspects of older patients and is especially useful for assessing frail individuals. Although a large proportion of hospitalized older adults demonstrate a high level of complexity, CGA was not developed specifically for this setting. Our aim was to evaluate the application of a CGA model for the clinical characterization and prognostic prediction of hospitalized older adults.
This was a prospective observational study including 746 patients aged 60 years and over who were admitted to a geriatric ward of a university hospital between January 2009 and December 2011, in Sao Paulo, Brazil. The proposed CGA was applied to evaluate all patients at admission. The primary outcome was in-hospital death, and the secondary outcomes were delirium, nosocomial infections, functional decline and length of stay. Multivariate binary logistic regression was performed to assess independent factors associated with these outcomes, including socio-demographic, clinical, functional, cognitive, and laboratory variables. Impairment in ten CGA components was particularly investigated: polypharmacy, activities of daily living (ADL) dependency, instrumental activities of daily living (IADL) dependency, depression, dementia, delirium, urinary incontinence, falls, malnutrition, and poor social support.
The studied patients were mostly women (67.4%), and the mean age was 80.5±7.9 years. Multivariate logistic regression analysis revealed the following independent factors associated with in-hospital death: IADL dependency (OR=4.02; CI=1.52-10.58; p=.005); ADL dependency (OR=2.39; CI=1.25-4.56; p=.008); malnutrition (OR=2.80; CI=1.63-4.83; p<.001); poor social support (OR=5.42; CI=2.93-11.36; p<.001); acute kidney injury (OR=3.05; CI=1.78-5.27; p<.001); and the presence of pressure ulcers (OR=2.29; CI=1.04-5.07; p=.041). ADL dependency was independently associated with both delirium incidence and nosocomial infections (respectively: OR=3.78; CI=2.30-6.20; p<.001 and OR=2.30; CI=1.49-3.49; p<.001). The number of impaired CGA components was also found to be associated with in-hospital death (p<.001), delirium incidence (p<.001) and nosocomial infections (p=.005). Additionally, IADL dependency, malnutrition and history of falls predicted longer hospitalizations. There were no significant changes in overall functional status during the hospital stay.
CGA identified patients at higher risk of in-hospital death and adverse outcomes, of which those with functional dependence, malnutrition and poor social support were foremost.
PMCID: PMC4265401  PMID: 25464932
Geriatric assessment; Outcomes; Hospital care; Delirium; Nutrition
16.  The Influence of Anxiety on the Progression of Disability 
To determine the influence of anxiety on the progression of disability and examine possible mediators of the relationship.
Community-based observational study.
Women’s Health and Aging Study I, a prospective observational study with assessments every 6 months over 3 years.
One thousand two functionally limited women aged 65 years and older.
Anxiety symptoms were assessed with 4 questions from the Hopkins Symptom Checklist (nervous or shaky, avoidance of certain things, tense or keyed up, fearful). Participants who reported experiencing 2 or more of these symptoms at baseline were considered anxious. Anxiety as a predictor of the onset of 4 types of disability was examined using Cox proportional hazard models. Three models were tested: an unadjusted model, a model adjusted for confounding variables (age, race, vision, number of diseases, physical performance, depressive symptoms), and a mediational model (benzodiazepine use, physical activity, emotional support).
Nineteen percent of women reported 2 or more symptoms of anxiety at baseline. Unadjusted models indicate that anxiety was associated with a greater risk of worsening disability: ADL disability (Hazard Risk = 1.40, 95% CI 1.10–1.79), mobility disability (HR = 1.41, 95% CI 1.06–1.86), lifting disability (HR = 1.54, 95% CI 1.20–1.97), and light housework disability (HR = 1.77, 95% CI 1.32–2.37). After adjusting for confounding variables, anxiety continued to predict the development of 2 types of disability: ADL disability (HR = 1.41, 95% CI 1.08–1.84) and light housework disability (HR = 1.56, 95% CI 1.14–2.14). Finally, benzodiazepine and psychotropic medication use, physical activity, and emotional support were not significant mediators of the effect of anxiety on the development of a disability.
Anxiety is a significant risk factor for the progression of disability among older women. Studies are needed to determine if treatment of anxiety delays or prevents disability.
PMCID: PMC1343490  PMID: 15667373
anxiety symptoms; disability; aged (65+)
17.  Ability to Walk 1/4 Mile Predicts Subsequent Disability, Mortality, and Health Care Costs 
Mobility, such as walking 1/4 mile, is a valuable but underutilized health indicator among older adults. For mobility to be successfully integrated into clinical practice and health policy, an easily assessed marker that predicts subsequent health outcomes is required.
To determine the association between mobility, defined as self-reported ability to walk 1/4 mile, and mortality, functional decline, and health care utilization and costs during the subsequent year.
Analysis of longitudinal data from the 2003–2004 Medicare Current Beneficiary Survey, a nationally representative sample of Medicare beneficiaries.
Participants comprised 5895 community-dwelling adults aged 65 years or older enrolled in Medicare.
Main Measures
Mobility (self-reported ability to walk 1/4 mile), mortality, incident difficulty with activities of daily living (ADLs), total annual health care costs, and hospitalization rates.
Key Results
Among older adults, 28% reported difficulty and 17% inability to walk 1/4 mile at baseline. Compared to those without difficulty and adjusting for demographics, socioeconomic status, chronic conditions, and health behaviors, mortality was greater in those with difficulty [AOR (95% CI): 1.57 (1.10-2.24)] and inability [AOR (CI): 2.73 (1.79-4.15)]. New functional disability also occurred more frequently as self-reported ability to walk 1/4 mile declined (subsequent incident disability among those with no difficulty, difficulty, or inability to walk 1/4 mile at baseline was 11%, 29%, and 47% for instrumental ADLs, and 4%, 14%, and 23% for basic ADLs). Total annual health care costs were $2773 higher (95% CI $1443-4102) in persons with difficulty and $3919 higher (CI $1948-5890) in those who were unable. For each 100 persons, older adults reporting difficulty walking 1/4 mile at baseline experienced an additional 14 hospitalizations (95% CI 8-20), and those who were unable experienced an additional 22 hospitalizations (CI 14-30) during the follow-up period, compared to persons without walking difficulty.
Mobility disability, a simple self-report measure, is a powerful predictor of future health, function, and utilization independent of usual health and demographic indicators. Mobility disability may be used to target high-risk patients for care management and preventive interventions.
PMCID: PMC3019329  PMID: 20972641
aging; mobility; mortality; disability; health care costs
18.  Longest held occupation in a lifetime and risk of disability in activities of daily living 
OBJECTIVES—To examine the association between the longest held occupation in a lifetime and risk of disability in activities of daily living (ADL) among elderly people (65 years and older) in northern Taiwan.
METHODS—A case-control design was used nested within two cohorts of a total of 2198 elderly people who had been followed up either between 1993 and 1997 or between 1996 and 1997. Cases were 360 elderly people with ADL disability within the study period. For each case, two sex matched controls were randomly sampled from the pool of elderly people free from ADL disability. Occupational data were collected through interviews conducted in 1997. Performed job contents were classified into occupational categories and occupation based social classes. Unconditional logistic regression techniques were used to estimate relative risk and 95% confidence intervals (95% CIs) of ADL disability.
RESULTS—Compared with people who were former legislators, government administrators, or business executives and managers, workers in agriculture, animal husbandry, forestry, or fishing (odds ratio (OR) 1.9, 95% CI 1.1 to 3.5) and workers in craft and related trades (OR 1.9, 95% CI 1.1 to 3.4) had significantly increased risks of subsequent ADL disability. Differential risks of ADL disability were found across social classes, with a significant dose-response trend in which unskilled blue collar workers had an 1.8 times higher risk of ADL disability than higher social classes of white collar workers.
CONCLUSIONS—After adjustment for education, there was still an inverse relation between risk of ADL disability and social class. Although total control for all the known risk factors for ADL disability among elderly people was impossible, the results tend to suggest a potential for an effect of longest held occupation in a lifetime on risk of ADL disability.

Keywords: activity of daily living; occupation; socioeconomic status
PMCID: PMC1739999  PMID: 10896962
19.  Weight Change and Lower Body Disability in Older Mexican Americans 
To examine the association between 2-year weight change and onset of lower body disability over time in older Mexican Americans.
Data were from the Hispanic Established Population for the Epidemiological Study of the Elderly (1993–2001). Weight change was examined by comparing baseline weight to weight at 2-year follow-up. Incidence of lower body disability was studied from the end of this period through an additional 5 years.
Five southwestern states: Texas, New Mexico, Colorado, Arizona, and California.
One thousand seven hundred thirty-seven noninstitutionalized Mexican-American men and women aged 65 and older who reported no limitation in activities of daily living (ADLs) and were able to perform the walk test at 2-year follow-up.
In-home interviews assessed sociodemographic factors, self-reported physician diagnoses of medical conditions (arthritis, diabetes mellitus, heart attack, stroke, hip fracture, and cancer), self-reported ADLs, depressive symptoms, and number of hospitalizations. Cognitive function, handgrip muscle strength, and body mass index (BMI) were obtained. The outcomes were any limitation of lower body ADL (walking across a small room, bathing, transferring from a bed to a chair, and using the toilet) and limitation on the walk test over subsequent 5-year follow-up period. General Estimation Equation (GEE) was used to estimate lower body disability over time.
Weight change of 5% or more occurred in 42.3% of the participants; 21.7% lost weight, 20.6% gained weight, and 57.7% had stable weight. Using GEE analysis, with stable weight as the reference, weight loss of 5% or more was associated with greater risk of any lower body ADL limitation (odds ratio (OR) = 1.43, 95% confidence interval (CI) = 1.06–1.95) and walking limitation (OR = 1.35, 95% CI = 1.03–1.76) after controlling for sociodemographic variables and BMI at baseline. Weight gain of 5% or more was associated with greater risk of any lower body ADL limitation (OR = 1.39, 95% CI = 1.02–1.89), after controlling for sociodemographic variables and BMI at baseline. When medical conditions, handgrip muscle strength, high depressive symptomatology, cognitive function, and hospitalization were added to the equation, the relationship between 2-year weight change (>5% loss or >5% gain) and lower body disability decreased.
Health conditions and muscle strength partially mediate the association between weight loss or gain and future loss of ability to walk and independently perform ADLs.
PMCID: PMC1941701  PMID: 16181172
weight change; ADL disability; walking; Mexican Americans
20.  Insufficient Help for ADL Disabilities and Risk for All-cause Hospitalization 
This study determined whether insufficient help for ADL disability, a potentially modifiable condition, significantly increases activities of daily living (ADL) disabled older adults’ risk for future hospital admissions.
Prospective study.
ADL disabled community living participants of the 1994, 1999, and/or 2004 National Long-term Care Survey (NLTCS).
5,884surveys were completed by Medicare recipients with one or more ADL disabilities.
Times to hospital admission in the year after the NLTCS community survey were obtained from linked Medicare claims. Insufficient ADL help for each ADL limitation was determined from a series of questions that were common to the three NLTCS community surveys.
Insufficient help for one or more ADL limitations was reported in 22% of surveys. Respondents to 3,629 surveys did not experience a hospital admission in the year after the survey. Among the remaining 2,255surveys, one admission occurred for 382 surveys, two admissions for 525 surveys, three admissions for 193 surveys, and four or more admissions for 155 surveys. Those reporting insufficient help were 14% (HR=1.14; 95% CI=1.01–1.28) more likely to experience one or more hospitalizations than those who do not report insufficient help after controlling for demographics, co-morbidities, prior hospitalizations and level of ADL disability.
Self-reports of insufficient help provide prognostic information beyond that which can be captured by typical health assessments. Greater recognition and referral for insufficient help for ADL disability may result in reduced rates of hospitalization in a population that is already at high risk for hospitalization.
PMCID: PMC4162318  PMID: 22587855
activities of daily living; disability; hospitalization; insufficient help
21.  Cross-Sectional Associations of Albuminuria and C-Reactive Protein With Functional Disability in Older Adults With Diabetes 
Diabetes Care  2011;34(3):710-717.
To examine the relationship between albuminuria, inflammation, and disability in older adults with diabetes.
Data were from 1,729 adults (≥60 years) with diabetes in the National Health and Nutrition Examination Survey, 1999–2008. Disability in activities of daily living (ADL), instrumental activities of daily living (IADL), leisure and social activities (LSA), general physical activities (GPA), and lower-extremity mobility (LEM) was obtained from self-reports. Urinary albumin-to-creatinine ratio (UACR) (mg/g) was categorized into normal (UACR <30 mg/g), microalbuminuria (UACR 30–300 mg/g), and macroalbuminuria (UACR >300 mg/g). C-reactive protein (CRP) levels were quantified by latex-enhanced nephelometry.
In the full-adjusted model, microalbuminuria was associated with disability in ADL, LSA, and LEM with corresponding odds ratios (ORs) (95% CIs) of 1.51 (1.16–1.98), 1.62 (1.23–2.14), and 1.34 (1.03–1.74), respectively, compared with participants without albuminuria. Macroalbuminuria was associated with disability in ADL, IADL, and LEM with corresponding ORs (95% CIs) of 1.94 (1.24–3.03), 1.93 (1.23–3.02), and 2.20 (1.38–3.49), respectively, compared with participants without albuminuria. Elevated CRP (>0.3 mg/dL) was associated with increased odds of disability in ADL and LEM, with corresponding ORs (95% CIs) of 1.28 (1.00–1.62) and 1.68 (1.34–2.11), respectively. Subjects with both albuminuria and elevated CRP had higher odds of disability than individuals with no albuminuria and normal CRP.
Albuminuria and inflammation were independent correlates for disability among older adults with diabetes. There was an interaction of albuminuria and elevated CRP on disability, suggesting that the presence of subclinical inflammation may amplify the effect of albuminuria on disability in older adults living with diabetes.
PMCID: PMC3041212  PMID: 21300788
22.  Cognitive and Physical Functions as Determinants of Delayed Age at Onset and Progression of Disability 
This study examined the association of cognitive and physical functions with age-related transition and progression of activities of daily living (ADL) disability in a population-based longitudinal cohort of nondisabled older adults.
A longitudinal population-based cohort study of 5,317 initially nondisabled older adults with an average age of 73.6 years of an urban Chicago community were interviewed annually for up to 8 years from 2000 through 2008. Cognitive function was assessed using a standardized global cognitive score and physical function using a combination of measured walk, tandem stand, and chair stand. A novel two-part model was used to access the relationship between cognitive and physical functions and age at onset and progression of ADL disability.
The sample consisted of 5,317 participants, 65% blacks, and 61% females. Twenty-five percent reported an onset of ADL disability during follow-up. After adjusting for confounders, lower cognitive and physical functions were associated with an increased risk for lower age at onset. Lower cognitive function was longitudinally associated with increased rate of progression of disability after onset. However, lower physical function did not alter the rate of progression of ADL disability.
Cognitive and physical functions were associated with age at onset. However, only cognitive function was associated with the rate of progression of ADL disability.
PMCID: PMC3636674  PMID: 22539654
Physical disability; Age at onset; Progression; Cognitive function; Physical function
23.  Health status in older hospitalized patients with cancer or non-neoplastic chronic diseases 
BMC Geriatrics  2005;5:10.
Whether cancer is more disabling than other highly prevalent chronic diseases in the elderly is not well understood, and represents the objective of the present study.
We used data from the Gruppo Italiano di Farmacovigilanza nell'Anziano (GIFA) study, a large collaborative observational study based in community and university hospitals located throughout Italy. Our series consisted of three groups of patients with non-neoplastic chronic disease (congestive heart failure, CHF, N = 832; diabetes mellitus, N = 939; chronic obstructive pulmonary disease, COPD, N = 399), and three groups of patients with cancer (solid tumors without metastasis, N = 813; solid tumors with metastasis, N = 259; leukemia/lymphoma, N = 326). Functional capabilities were ascertained using the activities of daily living (ADL) scale, and categorical variables for dependency in at least 1 ADL or dependency in 3 or more ADLs were considered in the analysis. Cognitive status was evaluated by the 10-items Hodgkinson Abbreviated Mental Test (AMT).
Cognitive impairment was more prevalent in patients with CHF (28.0%) or COPD (25.8%) than in those with cancer (solid tumors = 22.9%; leukemia/lymphoma = 19.6%; metastatic cancer = 22.8%). Dependency in at least 1 ADL was highly prevalent in patients with metastatic cancer (31.3% vs. 24% for patients with CHF and 22.4% for those with non-metastatic solid tumors, p < 0.001). In people aged 80 years or more, metastatic cancer was not associated with increased prevalence of physical disability. In multivariable analysis, metastatic cancer was associated with a greater prevalence of physical (OR 2.09, 95%CI 1.51–2.90) but not cognitive impairment (OR 1.34, 95%CI 0.94–1.91) with respect to CHF patients. Finally, diabetes was significantly associated with cognitive impairment (OR 1.40, 95%CI 1.11–1.78).
Cancer should not be considered as an ineluctable cause of severe cognitive and physical impairment, at least not more than other chronic conditions highly prevalent in older people, such as CHF and diabetes mellitus.
PMCID: PMC1201137  PMID: 16122389
24.  A Clinical Index to Stratify Hospitalized Older Adults According to Risk for New-Onset Disability 
Journal of the American Geriatrics Society  2011;59(7):10.1111/j.1532-5415.2011.03409.x.
Many older adults who are independent prior to hospitalization develop a new disability by hospital discharge. Early risk stratification for new-onset disability may improve care. Thus, this study’s objective was to develop and validate a clinical index to determine, at admission, risk for new-onset disability among older, hospitalized adults at discharge.
Data analyses derived from two prospective studies.
Two teaching hospitals in Ohio.
Eight hundred eighty-five patients aged 70 years and older were discharged from a general medical service at a tertiary care hospital (mean age 78, 59% female) and 753 patients discharged from a separate community teaching hospital (mean age 79, 63% female). All participants reported being independent in five activities of daily living (ADLs: bathing, dressing, transferring, toileting, and eating) 2 weeks before admission.
New-onset disability, defined as a new need for personal assistance in one or more ADLs at discharge in participants who were independent 2 weeks before hospital admission.
Seven independent risk factors known on admission were identified and weighted using logistic regression: age (80–89, 1 point; ≥90, 2 points); dependence in three or more instrumental ADLs at baseline (2 points); impaired mobility at baseline (unable to run, 1 point; unable to climb stairs, 2 points); dependence in ADLs at admission (2–3 ADLs, 1 point; 4–5 ADLs, 3 points); acute stroke or metastatic cancer (2 points); severe cognitive impairment (1 point); and albumin less than 3.0 g/dL (2 points). New-onset disability occurred in 6%, 13%, 18%, 34%, 35%, 45%, 50%, and 87% of participants with 0, 1, 2, 3, 4, 5, 6, and 7 or more points, respectively, in the derivation cohort (area under the receiver operating characteristic curve (AUC) =0.784), and in 8%, 10%, 27%, 38%, 44%, 45%, 58%, and 83%, respectively, in the validation cohort (AUC =0.784). The risk score also predicted (P<.001) disability severity, nursing home placement, and long-term survival.
This clinical index determines risk for new-onset disability in hospitalized older adults and may inform clinical care.
PMCID: PMC3839864  PMID: 21649616
hospitalization; prognosis; disability; activities of daily living
25.  Is a change in functional capacity or dependency in activities of daily living associated with a change in mental health among older people living in residential care facilities? 
Functional capacity and dependency in activities of daily living (ADL) could be important mediators for an association between physical exercise and mental health. The aim of this study was to investigate whether a change in functional capacity or dependency in ADL is associated with a change in depressive symptoms and psychological well-being among older people living in residential care facilities, and whether dementia can be a moderating factor for this association.
A prospective cohort study was undertaken. Participants were 206 older people, dependent in ADL, living in residential care facilities, 115 (56%) of whom had diagnosed dementia. Multivariate linear regression, with comprehensive adjustment for potential confounders, was used to investigate associations between differences over 3 months in Berg Balance Scale (BBS) and Geriatric Depression Scale (GDS-15) scores, and in BBS and Philadelphia Geriatric Center Morale Scale (PGCMS) scores. Associations were also investigated between differences in Barthel ADL Index and GDS-15 scores, and in Barthel ADL Index and PGCMS scores.
There were no significant associations between changes in scores over 3 months; the unstandardized β for associations between BBS and GDS-15 was 0.026 (P=0.31), BBS and PGCMS 0.045 (P=0.14), Barthel ADL Index and GDS-15 0.123 (P=0.06), and Barthel ADL Index and PGCMS −0.013 (P=0.86). There were no interaction effects for dementia.
A change in functional capacity or dependency in ADL does not appear to be associated with a change in depressive symptoms or psychological well-being among older people living in residential care facilities. These results may offer one possible explanation as to why studies of physical exercise to influence these aspects of mental health have not shown effects in this group of older people.
PMCID: PMC3843606  PMID: 24379657
aged; residential facilities; dementia; frail elderly; activities of daily living; physical fitness; mental health; depression; quality of life

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