The North Carolina Area Health Education Centers Library and Information Services (NC AHEC LIS) Network provides library outreach services to rural health care providers in all nine AHEC regions of North Carolina. Over the last twenty-five years, the AHEC and university-based librarians have collaborated to create a model program for support of community-based clinical education and information access for rural health care providers. Through several collaborative projects, they have supported Internet access for rural health clinics. The NC AHEC Digital Library—under development by NC AHEC, University of North Carolina at Chapel Hill, Duke University, East Carolina University, and Wake Forest University—will further extend access to electronic biomedical information and resources to health professionals in a statewide digital library.
To use unweighted counts of dependencies in Activities of Daily Living (ADLs) to assess the impact of functional impairment requires an assumption of equal preferences for each ADL dependency. To test this assumption, we analyzed standard gamble utilities of single and combination ADL dependencies among older adults. Study Design and Setting: Four hundred older adults used multimedia software (FLAIR1) to report standard gamble utilities for their current health and hypothetical health states of dependency in each of 7 ADLs and 8 of 30 combinations of ADL dependencies.
Utilities for health states of multiple ADL dependencies were often greater than for states of single ADL dependencies. Dependence in eating, the ADL dependency with the lowest utility rating of the single ADL dependencies, ranked lower than 7 combination states. Similarly, some combination states with fewer ADL dependencies had lower utilities than those with more ADL dependencies. These findings were consistent across groups by gender, age, and education.
Our results suggest that the count of ADL dependencies does not adequately represent the utility for a health state. Cost-effectiveness analyses and other evaluations of programs that prevent or treat functional dependency should apply utility-weights rather than relying on simple ADL counts.
Quality of Life; Older Adults; Activities of Daily Living; Standard Gamble Utilities; Functional Dependency; Health Preferences
An Area Health Education Center (AHEC) system has been established in California to address the maldistribution of physicians and other health care professionals. The AHEC program uses educational incentives to recruit and retain health care personnel in underserved areas by linking the academic resources of university health science centers with local educational and clinical facilities. The medical schools, working in partnership with urban or rural AHECs throughout the state, are implementing educational programs to attract trainees and licensed professionals to work in underserved communities. The California AHEC project entered its fifth year in October of 1983 with the participation of all eight medical schools and the Charles Drew Postgraduate School of Medicine, 35 other health professions schools, 17 independent AHECs and more than 400 clinical training sites. Educational programs are reaching more than 22,000 students and practicing health professionals throughout California. We review the current status of the California AHEC system and use the AHEC programs at Loma Linda University to illustrate the effect this intervention is having.
Retinal microvascular signs are associated with systemic conditions and cognitive decline. We studied the associations of microvascular changes, measured by retinal signs, with disability in performing activities of daily living (ADL).
Prospective cohort study.
1487 participants in the Cardiovascular Health Study (mean age 78 years) who were free of ADL disability and had available data on retinal signs and carotid intima-media thickness (IMT) at the 1998–99 visit.
Main Outcome Measure
Incident ADL disability, defined as self-reported difficulty in performing any ADLs, by the presence of retinal signs and advanced carotid atherosclerosis, defined by carotid IMT ≥ 80th percentile or ≥ 25% stenosis; and potential mediation by cerebral microvascular disease on brain imaging or by executive dysfunction, slow gait, and depressive mood that are symptoms of frontal subcortical dysfunction.
During the median follow-up of 3.1 years (maximum 7.8 years), participants with ≥ 2 retinal signs had a higher rate of disability than those with < 2 retinal signs (10.1% versus 7.1%; adjusted hazards ratio, 1.45; 95% confidence interval, 1.24–1.69; P < 0.001). There was no evidence of interaction by advanced carotid atherosclerosis (P > 0.10). The association seemed to be partially mediated by executive dysfunction, slow gait, and depressive symptoms, but not by cerebral microvascular disease on brain imaging.
These results provide further support for the pathophysiologic and prognostic significance of microvascular disease in age-related disability. However, it remains to be determined how to best utilize retinal photography in the clinical risk prediction.
Functional outcomes of clinical trials are often reported as number of dependencies in activities of daily living (ADLs). Quality-weighting for the ADLs has not been reported. We designed and pilot-tested ADLIB (ADL Index Builder), a multimedia computer program, that presents ADL health states to subjects and elicits from subjects a rating for the quality of life of each health state. Subjects, who were patients over age 50 without previous computer experience, found the program easy to use. Health care professionals specializing in geriatrics confirmed that the ADL presentations used in the program are in accord with typical practice in scoring ADLs. We plan to use the program to obtain population-based preference ratings that can be used to assess efficacy of clinical trials and to provide quality-weights for cost-effectiveness analysis.
A study to determine the impact that the Area Health Education Center type of programs may have on health science libraries was conducted by the Extramural Programs, National Library of Medicine, in conjunction with a contract awarded by the Bureau of Health Manpower, Health Resources Administration, to develop an inventory of the AHEC type of projects in the United States. Specific study tasks included a review of these programs as they relate to library and information activities, on-site surveys on the programs to define their needs for library services and information, and a categorization of library activities. A major finding was that health science libraries and information services are generally not included in AHEC program planning and development, although information and information exchange is a fundamental part of the AHEC type of programs. This study suggests that library inadequacies are basically the result of this planning failure and of a lack of financial resources; however, many other factors may be contributory. The design and value of library activities for these programs needs explication.
To examine the cross-sectional associations between activity of daily living (ADL) limitation stage and specific physical and mental conditions, global perceived health, and unmet needs for home accessibility features of community-dwelling adults aged 70 and older.
Nine thousand four hundred forty-seven community-dwelling persons interviewed through the Second Longitudinal Study of Aging (LSOA II).
Six ADLs organized into five stages ranging from no difficulty (0) to unable (IV).
ADL stage showed strong ordered associations with perceived health, dementia severe enough to require proxy use, and history of stroke. For example, the relative risks (RRs) defined as risk of being at Stages I, II, III, or IV divided by risk of being at Stage 0 for those with dementia ranged from 3.2 (95% confidence interval (CI) = 2.4–4.4) to 41.9 (95% CI = 19.6–89.6) times the RRs for those without dementia. The RR ratios (RRR) comparing respondents who perceived unmet need for accessibility features in the home to those without these perceptions peaked at Stage III (RRR = 17.8, 95% CI = 13.0–24.5) and then declined at Stage IV. All models were adjusted for age, sex, and race.
ADL stages showed clinically logical associations with other health-related concepts, supporting external validity. Findings suggest that specificity of chronic conditions will be important in developing strategies for disability reduction. People with partial rather than complete ADL limitation appeared most vulnerable to unmet needs for home accessibility features.
activities of daily living; staging; chronic disease; environment; biopsycho-ecological framework
To examine whether symptomatic arthritis in middle age predicts the earlier onset of functional difficulties (difficulty with activities of daily living (ADLs) and walking) that are associated with loss of independence in older persons.
Prospective longitudinal study.
The Health and Retirement Study, a nationally representative sample of persons aged 50 to 62 at baseline who were followed for 10 years.
Seven thousand five hundred forty-three subjects with no difficulty in mobility or ADL function at baseline.
Arthritis was measured at baseline according to self-report. The primary outcome was time to persistent difficulty in one of five ADLs or mobility (walking several blocks or up a flight of stairs). Difficulty with ADLs or mobility was assessed according to subject interview every 2 years. Analyses were adjusted for other co-morbid conditions, body mass index, exercise, and demographic characteristics.
Twenty-nine percent of subjects reported arthritis at baseline. Subjects with arthritis were more likely to develop persistent difficulty in mobility or ADL function over 10 years of follow-up (34% vs 18%, adjusted hazard ratio (HR) = 1.63, 95% confidence interval (CI) = 1.43–1.86). When each component of the primary outcome was assessed separately, arthritis was also associated with persistent difficulty in mobility (30% vs 16%, adjusted HR = 1.55, 95% CI = 1.41–1.71) and persistent difficulty in ADL function (13% vs 5%, adjusted HR = 1.85, 95% CI = 1.58–2.16).
Middle-aged persons who report a history of arthritis are more likely to develop mobility and ADL difficulties as they enter old age. This finding highlights the need to develop interventions and treatments that take a life-course approach to preventing the disabling effect of arthritis.
arthritis; ADL; mobility
Previous research shows that limitations in activities of daily living (ADLs) are related to greater psychological distress. This study uses a synthesis of life course and stress process perspectives to examine how social support resources and the timing of limitations intersect to shape the relationship between ADL limitations and changes in psychological distress.
Data are derived from a longitudinal study of adults aged 65 and older in the Washington, DC, metropolitan area over a 2-year period (2001–2003).
ADL limitations are positively related to change in depressive symptoms. This relationship is weakened for older individuals, but only at higher levels of perceived social support.
The contribution of this research is to offer a more nuanced view of the mental health consequences of physical limitations in late life by demonstrating that perceived social support provides an important context for age-variegated associations between ADL limitations and changes in psychological distress.
Activities of daily living; ADLs; Depression; Life course perspective; Mental health; Physical limitations; Psychological distress; Stress process perspective; Social support; Timing
Limitation in the activities of daily living (ADLs) is strongly prognostic for mortality. Current ADL assessments based on numbers of limitations (counts) obscure the particular activities limited, thus lacking clinical interpretability.
To examine the independent association of 5 stages of ADL with mortality after accounting for known diagnostic and sociodemographic risk factors.
For five stages (ADL 0 to IV), describing both the severity and pattern of ADLs limited, we estimated unadjusted life expectancies and adjusted associations with mortality using a Cox proportional hazards regression model.
Included were 9,447 persons 70 years of age and older from the second Longitudinal Study of Aging.
1-, 5-, and 10-year survival and time to death.
For those with no ADL limitations, the median life expectancy was 10.6 years compared to 6.5, 5.1, 3.8, and 1.6 years for those at ADL I, II, III, and IV, respectively. The sociodemographic and diagnostic-adjusted hazard of death at 1 year was 5-fold greater at stage IV compared to stage 0 (hazard ratio=5.6; 95% confidence interval, 3.8–8.3). The associations of ADL stage with mortality declined over time, but remained statistically significant at 5 and 10 years.
ADL stage continued to explain mortality risk after adjusting for known risk factors including advanced age, stroke, and cancer. ADL stages might aid clinical care planning and policy as a powerful prognostic indicator particularly of short-term mortality, improving on current ADL measures by profiling activity limitations of relevance to determining community support needs.
Activities of Daily Living; Staging; Mortality; Risk factors
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.
ADL disability; infections; oldest-old; general population; older people
To identify the factors that predict recovery in activities of daily living (ADLs) among disabled older persons living in the community.
Prospective cohort study with 2-year follow-up.
213 men and women 72 years or older, who reported dependence in one or more ADLs.
MEASUREMENTS AND MAIN RESULTS
All participants underwent a comprehensive home assessment and were followed for recovery of ADL function, defined as requiring no personal assistance in any of the ADLs within 2 years. Fifty-nine participants (28%) recovered independent ADL function. Compared with those older than 85 years, participants aged 85 years or younger were more than 8 times as likely to recover their ADL function (relative risk [RR] 8.4; 95% confidence interval [CI] 2.7, 26). Several factors besides age were associated with ADL recovery in bivariate analysis, including disability in only one ADL, self-efficacy score greater than 75, Folstein Mini-Mental State Examination (MMSE) score of 28 or better, high mobility, score in the best third of timed physical performance, fewer than five medications, and good nutritional status. In multivariable analysis, four factors were independently associated with ADL recovery—age 85 years or younger (adjusted RR 4.1; 95% CI 1.3, 13), MMSE score of 28 or better (RR 1.7; 95% CI 1.2, 2.3), high mobility (RR 1.7; 95% CI 1.0, 2.9), and good nutritional status (RR 1.6; 95% CI 1.0, 2.5).
Once disabled, few persons older than 85 years recover independent ADL function. Intact cognitive function, high mobility, and good nutritional status each improve the likelihood of ADL recovery and may serve as markers of resiliency in this population.
activities of daily living (ADLs); recovery; elderly; prospective cohort study; prognosis
The Area Health Education Center (AHEC) Program is a Federal initiative funded by the Public Health Service. The goal of the program is to improve the distribution and quality of training for health professionals. Funds are awarded to schools of medicine or osteopathy which in turn subcontract with at least two other health professional schools. Each project recipient must establish an AHEC center to plan and coordinate community-based educational experiences for health professions students in designated health shortage areas. The AHEC program fosters interdisciplinary training among health professionals. As part of the basic program thrust, some AHECs have included the social work profession in their program design. The Massachusetts AHEC, through Boston University's School of Social Work, established a health care concentration and interdisciplinary rotation that included students from social work, psychology, nursing, and medicine. Other examples of AHEC-sponsored training are presented from Baltimore, the eastern shore of Virginia, and several centers in Massachusetts. Through the AHEC training mechanism, social work students as well as practitioners in the field have the opportunity to encounter the most current and urgent issues in health care practice.
Observational cohort design.
To quantify the frequencies and magnitudes of neck motion during daily activities in healthy subjects.
Summary of Background Data
Previous studies have measured the maximum excursions during re-created ADLs in lab settings, but there is a lack of information available on frequencies and excursions of neck motion with ADLs in non-artificial settings.
Ten healthy young adults were fitted with a portable motion measurement device that recorded movement about each primary axis. Participants were instructed to wear the unit continuously over a 5-day period and record their daily activities with corresponding times. After the collection period, subjects' activity logs were analyzed and data were partitioned into five categories which provided the most primary representation of ADLs: athletics, work, travel, sleep, and miscellaneous. Each category was further divided into increasingly specific activities (e.g. running and walking). Frequency of motions within 5° increments was determined and an hourly rate was calculated for each activity. Median motion about each axis for each activity was also determined.
The total number of movements per hour for all axes, regardless of amplitude, was highest during athletic activity and lowest during sleeping. The majority of movements (92% of athletic activity, 90% of work) required less than 25° of lateral bending, while greater range of movement requirements were observed for flexion-extension and axial rotation. The median range of motion along all axes was highest for athletic activity and lowest for sleeping.
The results of this study provide a baseline of the frequency and magnitude of neck motion during normal ADLs for the specified population. These findings can assist physicians and physical therapists in determining the extent of disability and identifying activities that will likely be problematic for patients with limited cervical motion.
cervical spine; cervical range of motion; activities of daily living; continuous motion monitoring
To determine the relative effect of five chronic conditions on four representative universal health outcomes.
Cardiovascular Health Study.
Five thousand two hundred and ninety-eight community-living participants aged 65 and older.
Multiple regression and Cox models were used to determine the effect of heart failure (HF), chronic obstructive pulmonary disease (COPD), osteoarthritis, depression, and cognitive impairment on self-rated health, 12 basic and instrumental activities of daily living (ADLs and IADLs), six-item symptom burden scale, and death.
Each condition adversely affected self-rated health (P<.001) and ADLs and IADLs (P<.001). For example, persons with HF performed 0.70 ± 0.08 fewer ADLs and IADLs than those without; persons with depression and persons with cognitive impairment performed 0.59 ± 0.04 and 0.58 ± 0.06 fewer activities, respectively, than those without these conditions. Depression, HF, COPD, and osteoarthritis were associated with 1.18 ± 0.04, 0.40 ± 0.08, 0.40 ± 0.05, and 0.57 ± 0.03 more symptoms, respectively, in individuals with these conditions than in those without. HF (hazard ratio (HR) = 2.84, 95% confidence interval (CI) = 1.97–4.10), COPD (2.62, 95% CI = 1.94–3.53), cognitive impairment (2.05, 95% CI = 1.47–2.85), and depression (1.47, 95% CI = 1.08–2.01) were each associated with death within 2 years. Several paired combinations of conditions had synergistic effects on ADLs and IADLs. For example, individuals with HF plus depression performed 2.0 fewer activities than persons with neither condition, versus the 1.3 fewer activities expected from adding the effects of the two conditions together.
Universal health outcomes may provide a common metric for measuring the effects of multiple conditions and their treatments. The varying effects of the conditions across universal outcomes could inform care priorities.
multiple chronic conditions; patient-reported outcomes; universal health outcomes
Establishing an interface between area health education center (AHEC) libraries and medical school libraries requires careful planning, including: the overall plan, needs assessment, resource evaluation, a developmental plan, monitoring and evaluation, institutional agreements, and publicity. This paper reports on the development of AHEC libraries in North Dakota.
To determine the efficacy of a zoster vaccine on herpes zoster related interference with activities of daily living (ADL) and health-related quality of life (HRQL).
Randomized double-blind placebo controlled trial.
22 US sites.
38,546 women and men ≥60 years of age.
Zoster vaccine or placebo.
Herpes zoster Burden of Interference with ADL and HRQL using ratings from the Zoster Brief Pain Inventory and SF-12 Mental and Physical Component Scores. Vaccine efficacy was calculated for the modified-intention-to-treat trial population and solely among those subjects who developed herpes zoster.
For the modified-intention-to-treat population, the overall zoster vaccine efficacy was 66% (95% CI: 55, 74) for Zoster Brief Pain Inventory ADL Burden of Interference Score and 55% (95% CI: 48, 61) for both the SF-12 Mental and Physical Component Scores. Among subjects who developed herpes zoster, zoster vaccine reduced the Zoster Brief Pain Inventory ADL Burden of Interference Score by 31% (95% CI: 12, 51) respectively, and did not significantly reduce the impact on HRQL.
Zoster vaccine reduced the burden of herpes zoster related interference with ADL in the population of vaccinees and among vaccinees who developed herpes zoster. Zoster vaccine reduced the impact of herpes zoster on HRQL in the population of vaccinees but not among vaccinees who developed herpes zoster.
herpes zoster; herpes zoster vaccine; aged; activities of daily living
In a cross-sectional study, we investigated the relationship between age, physical health, social and economic resources, functional status, activities of daily living (ADL) and disease-related variables of 227 patients with cancer. Using multidimensional outcome measures we examined age differences in three age groups (< 45, 46-65, > 65 years) and identified predictors of performing ADL. The results indicated that older patients have outcomes similar to those of younger patients. There were no significant differences in quality of life, performance status and physical health among the three age groups. The only areas where age-related differences were found were co-morbidity and cancer-related impairments. Patients aged 45-65 years and patients 65 years and older reported a higher level of co-morbidity and more cancer-related impairments than those aged 45 and younger. Although older patients had higher co-morbidity, they showed similar Karnofsky Performance Status (KPS) scores to those of their younger counterparts. The regression analysis revealed social resources, self-reported health, performance status and complexity of care as significant predictors of patients' ADL, but not age, co-morbidity or severity of treatment. The findings support the conclusion that differences in performing ADL between younger and older patients with cancer are minimal and tend to be due to co-morbidity. Thus, treatment should be decided by a patient's physical health rather than by age.
Objectives. To investigate the link between neurocognitive measures and various aspects of daily living (ADL and IADL) in women and men with mild Alzheimer's disease (AD). Methods. Participants were 202 AD patients (91 male, 111 female) with CDR global scores of ≤1. ADLs and IADLs ratings were obtained from caregivers. Cognitive domains were assessed with neuropsychological testing. Results. Memory and executive functioning were related to IADL scores. Executive functioning was linked to total ADL. Comparisons stratified on gender found attention predicted total ADL score in both men and women. Attention predicted bathing and eating ability in women only. Language predicted IADL functions in men (food preparation) and women (driving). Conclusions. Associations between ADLs/IADLs and memory, learning, executive functioning, and language suggest that even in patients with mild AD, basic ADLs require complex cognitive processes. Gender differences in the domains of learning and memory area were found.
To determine whether participants with mild cognitive impairment (MCI) differ from cognitively normal (NC) older adults on traditional and novel informant-based measures of activities of daily living (ADL) and to identify cognitive correlates of ADLs among participants with MCI.
University medical setting.
Seventy-seven participants (NC: N = 39; MCI: N = 38), 60 to 90 years old (73.5 ± 6.6 years; 53% female).
Neuropsychological and ADL measures.
Neuropsychological tests were administered to NC and MCI participants. Informants completed the Lawton and Brody Instrumental Activities of Daily Living and Physical Self-Maintenance Scale, including instrumental (IADL) and basic ADL (BADL) scales, as well as the Functional Capacities for Activities of Daily Living (FC-ADL), an error-based ADL measure.
No statistically or clinically significant between-group differences emerged for the BADL or IADL subscales. However, a robust difference was noted for the FC-ADL scale (MCI errors > NC errors; F(1,75) = 13.6, p <0.001; d = 0.84). Among MCI participants, correlations revealed that a measure of verbal learning was the only neuropsychological correlate of FC-ADL total score (r =-0.39, df = 36, p = 0.007). No neuropsychological measures were significantly associated with the IADL or BADL subscale score.
Traditional measures assessing global ADLs may not be sensitive to early functional changes related to MCI; however, error-based measures may capture the subtle evolving functional decline associated with MCI. Among MCI participants, early functional difficulties are associated with verbal learning performance, possibly secondary to the hallmark cognitive impairment associated with this cohort.
Instrumental activities of daily living; MCI; memory; functional errors; neuropsychology
Although physical function is believed to be an important predictor of outcomes in older people, it has seldom been used to adjust for prognosis or case mix in evaluating mortality rates or resource use. The goal of this study was to determine whether patients’ activity of daily living (ADL) function on admission provided information useful in adjusting for prognosis and case mix after accounting for routine physiologic measures and comorbid diagnoses.
The general medical service of a teaching hospital.
Medical inpatients (n = 823) over age 70 (mean age 80.7, 68% women).
Independence in ADL function on admission was assessed by interviewing each patient’s primary nurse. We determined the APACHE II Acute Physiology Score (APS) and the Charlson comorbidity score from chart review. Outcome measures were hospital and 1-year mortality, nursing home use in the 90 days following discharge, and cost of hospitalization. Patients were divided into four quartiles according to the number of ADLs in which they were dependent.
ADL category stratified patients into groups that were at markedly different risks of mortality and higher resource use. For example, hospital mortality varied from 0.9% in patients dependent in no ADL on admission, to 17.4% in patients dependent in all ADLs. One-year mortality ranged from 17.5% to 54.9%, nursing home use from 3% to 33%, and hospital costs varied by 53%. In multivariate analyses controlling for APS, Charlson scores, and demographic characteristics, compared with patients dependent in no ADL, patients dependent in all ADLs were at greater risk of hospital mortality (odds ratio [OR] 13.7; 95% confidence interval [CI] 3.1–58.8), 1-year mortality (OR 4.4; 2.7–7.4), and 90-day nursing home use (OR 14.9; 6.0–37.0). The DRG-adjusted hospital cost was 50% higher for patients dependent in all ADLs. ADL function also improved the discrimination of hospital and 1-year mortality models that considered APS, or Charlson scores, or both.
ADL function contains important information about prognosis and case mix beyond that provided by routine physiologic data and comorbidities in hospitalized elders. Prognostic and case–mix adjustment methods may be improved if they include measures of function, as well as routine physiologic measures and comorbidity.
prognosis; case mix; activities of daily living; severity; functional status
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.
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.
hospitalization; functional decline; recovery
To assess the predictive value of five performance-based measures for the onset of difficulty in basic activities of daily living (ADL).
A prospective cohort study; home visits every 6 months for 18 months.
Community-dwelling older adults, n=110, (mean age, 80; SD, 7.0; range, 67-98 years) who reported no difficulty in basic ADLs.
The Short Physical Performance Battery (SPPB), gait speed, Berg Balance Scale (BBS), grip strength, and Timed Up & Go Test (TUG) were evaluated at baseline. Seven ADL items were assessed at baseline, 6, 12 and 18 months. The onset of basic ADL disability was self-report of difficulty in any of the 7 ADL items. Logistic regression models were fitted for each of the physical performance measures to predict onset of basic ADL difficulty at 6, 12, and 18 months.
After controlling for age, co-morbid conditions, and gender, the BBS was the most consistent and best predictor for the onset of basic ADL difficulty over an 18-month period (6 months, c-statistic=.725 (.60, .85); 12 months, c-statistic=.840 (.75, .93); 18 months, c-statistic=.821 (.71, .93)). The SPPB showed excellent predictive value for the onset of difficulty at 12 months. The number of older adults completed the 6, 12, and 18-month follow-up visits were 95, 89, and 75, respectively.
BBS, followed by SPPB, TUG, gait speed and grip strength were predictive for the onset of basic ADL difficulty over an 18-month period in community-dwelling older adults. Screening nondisabled older adults with simple performance tests could allow clinicians to identify those at risk for ADL difficulty, and may help to detect early functional decline.
activities of daily living; physical performance measure; Berg balance scale; short physical performance battery; gait speed
To examine a new method for classifying disability subtypes by combining self-reported and performance-based tools to predict mortality in Chinese older adults.
Prospective cohort study.
Community-dwelling old adults.
16,020 Chinese adults over age 65 from the Chinese Longitudinal Healthy Longevity Survey (CLHLS).
Self-reported Basic Activities of Daily Living (ADLs) and physical performance (PP) tests (chair standing, lifting a book from floor, turning 360 degrees) cross-classified to create mutually exclusive disability subtypes: subtype 0 (no limitations in PP or ADL), subtype 1 (limitations in PP, no limitations in ADL), subtype 2 (no limitations in PP, limitations in ADL), and subtype 3 (limitations in both PP and ADL). Outcome was mortality over three years.
Cox proportional hazard models, controlling for sociodemographics, living situation, healthcare access, social support, health status, and life style, showed that older adults without any limitations in ADL or PP had significantly lower mortality risk than those with other disability subtypes, and that there was a graded pattern of increased mortality according to subtypes 1, 2, and 3 (hazard ratios = 1.31 [1.20, 1.42], 1.39 [1.23, 1.59], and 1.88 [1.72, 2.05], respectively). When compared with the average survival curve in the cohort, subtypes of isolated performance deficits or self-reported disability did not substantially discriminate risks of death over three years.
Combined use of self-reported and physical performance tools is necessary when screening for mutually exclusive disability subtypes that confer significantly elevated or decreased mortality risks to a population of older adults.
physical disability; activities of daily living; physical performance; mortality
To describe the independent contributions of selected medical conditions to the disparity between black and white people in disability rates, controlling for demographic and socioeconomic factors.
Cross-sectional analysis of a community-based cohort.
Urban and rural counties of central North Carolina.
Two thousand nine hundred sixty-six adults aged 68 and older participating in the Duke Established Populations for Epidemiologic Studies of the Elderly (EPESE).
Self-reported data on sociodemographic characteristics and medical conditions, Short Portable Mental Status Questionnaire, activities of daily living (ADLs).
Fifty-five percent of the cohort was black. Blacks were more likely than whites to report disability (odds ratio = 1.39, 95% confidence interval = 1.15–1.68). Controlling for age, sex, marital status, and socioeconomic status, blacks were more likely to be obese and have diabetes mellitus, and less likely to report vision problems, fractures, and heart attacks. The higher prevalence of obesity and diabetes mellitus in blacks, after adjustment for sociodemographic factors, accounted for more than 30% of the black–white difference in disability. Conversely, the black–white disability gap would be approximately 45% wider if whites had a lower prevalence of fractures and vision impairment, similar to their black peers.
Higher rates of obesity and diabetes mellitus in older black Americans account for a large amount of the racial disparity in disability, even after controlling for socioeconomic differences. Culturally appropriate interventions that lower the prevalence or the functional consequences of obesity and diabetes mellitus in blacks could substantially decrease this racial health disparity.
race; health disparity; aged; comorbidity; function