Disability in older adults. 1: Prevalence, causes, and consequences

The effects of disability on an aging population's health and welfare are an important issue in gerontological research. The rapid growth of the elderly population and increases in longevity have led to an ongoing debate about whether longer lives can be matched by longer active lives that are free from disability. After a detailed review of current disability literature, the authors discuss the impact of disability in the elderly, defining disability and reviewing three classes of disability--physical, mental, and social. Both subjective and objective disability measures are described, and disability trends and prevalence rates are reviewed and compared cross culturally, by gender, by age, and over time. The path from chronic disease to disability is described and the consequences of living with disability are discussed in terms of family burdens and the increased need for medical care.     

Cost of treating stroke in an Irish teaching hospital

In contrast to CHD and cancer, the burden of stroke lies with long term disability as opposed to death and it is the most common cause of neurological disability in the western world. Consequently such patients frequently require longer acute hospital stays followed by lengthy periods of rehabilitation where such services are available, long term nursing care or indefinite dependency on community care. Inevitably stroke is a major economic burden on healthcare systems. It has been estimated that approximately 6% of total healthcare resources are consumed in the management of this condition a figure which is expected to grow with an increasing elderly population. Due to the high level of disability caused by stroke, patients often require longer and therefore costly periods of acute hospital stay. The aim of this study is to determine the cost of treating an acute episode of ischaemic stroke in an Irish teaching hospital. The costing evaluation was from the hospital admission perspective and the strategy used was a microcosting detailed collection of resources used on patients admitted to St. James's hospital between January 1999 and March 2000. The average cost of a hospital admission for the treatment of an episode of acute ischaemic stroke was 6,722 euros. The average cost per day was calculated at 263 euros. Approximately 83% of hospital costs were associated with ward costs whereas medications accounted for just 1% of total costs. The projected cost for the treatment of stroke in euros using the consumer price index for October 2002 would be 7,686 euros. The availability of Irish cost data is essential for the assessment of the cost effectiveness of therapeutic interventions for the treatment of stroke in our healthcare system.     

Genes,physical fitness and ageing

Persons aged 80 years and older are the fastest growing segment of the population. As more individuals live longer, we should try to understand the mechanisms involved in healthy ageing and preserving functional independence in later life. In elderly people, functional independence is directly dependent on physical fitness, and ageing is inevitably associated with the declining functions of systems and organs (heart, lungs, blood vessels, skeletal muscles) that determine physical fitness. Thus, age-related diminished physical fitness contributes to the development of sarcopenia, frailty or disability, all of which severely deteriorate independent living and thus quality of life. Ageing is a complex process involving many variables that interact with one another, including – besides lifestyle factors or chronic diseases – genetics. Thus, several studies have examined the contribution of genetic endowment to a decline in physical fitness and subsequent loss of independence in later life. In this review, we compile information, including data from heritability, candidate-gene association, linkage and genome-wide association studies, on genetic factors that could influence physical fitness in the elderly.     

Disability in older adults. 2: Physical activity as prevention

In this 2nd article in the series on older adults (persons aged > or = 65 years), the role of physical activity in preventing disability associated with aging in the absence of specific illnesses is discussed, and different types of activities and the measures of outcome are described. Evidence for physical activity as a prevention measure is restricted to primary and secondary prevention because the application of physical activity for tertiary prevention of disability is limited. Chronic disease is considered in the context of its influence on disability only when physical activity offers some potential benefit to elderly persons.     

The physical, psychological and social impact of psoriasis

Psoriasis is a chronic, disabling skin disease affecting up to 2 percent of the population. Little is known about how physical, psychological and social features of the illness interact to create a negative impact. In this article, a biopsychosocial model of the impact of psoriasis is described, and results from a survey of 317 psoriasis patients are presented. The types of functional disability, psychological distress and disease-related stressors are described for highly strained patients (i.e. those with disease-related suicidal ideation) and compared with less strained patients (i.e. those without suicidal ideation). As predicted by the model, significantly more disability, psychological distress and disease-related stressors are found among highly strained patients. Logistical regression analysis revealed that strain is more strongly associated with disability, distress and disease-related stress level than with disease severity. Implications for research and clinical interventions are discussed.     

Predictors of homelessness among older adults in New York city: disability, economic, human and social capital and stressful events

We interviewed 61 housed and 79 homeless adults aged 55 and over about disability; economic, human and social capital; and stressful life events prior to becoming homeless. Over half of the homeless group had previously led conventional lives. Human capital, social capital and life events were more important than disability or economic capital in predicting homelessness. The homeless adults were younger, more likely to be male and better educated than housed adults, but had shorter job tenure and fewer social ties. Homeless adults faced multiple, cascading risks, including job loss and housing loss. Implications for prevention are discussed.     

Using mobile phones in healthcare management for the elderly

The increasing average life expectancy is simultaneously increasing the incidence of chronic diseases and the number of healthy elderly people, consequently leading to an increased demand for healthcare management methods that do not involve hospital visits. The development of health management services involving mobile phones will change the focus of medical services from hospital visits and treatments to managing the health decisions made by individuals in their daily lives. However, the elderly may experience specific difficulties in adapting to constantly evolving services.This study reviews various health-related devices such as mobile phones that are available for providing healthcare to the elderly, and the different ways of using them. As the use of mobile phone increases, it is expected that elderly mobile phone users will also be able to regularly check their health status at any time and place.The issues of an ageing population pertain to the entire society rather than only to the elderly, which make mobile-phone-based medical informatics as a health management service a worthy goal.     

The relationship between nutrition and frailty: Effects of protein intake,nutritional supplementation,vitamin D and exercise on muscle metabolism in the elderly. A systematic review

BackgroundFrailty is a geriatric syndrome that predicts the onset of disability, morbidity and mortality in elderly people; it is a state of pre-disability and is reversible.The aim of this review is to assess how nutrition influences both the risk of developing frailty and its treatment.Data sourcesWe searched two databases, PubMed and Web of Science. We included epidemiologic studies and clinical trials carried out on people aged over 65 years. We included 32 studies with a total of over 50,000 participants.ResultsThe prevalence of frailty is ranges from 15% among elderly people living in the community to 54% among those hospitalized. Furthermore, the prevalence of frailty is disproportionately high among elderly people who are malnourished. Malnutrition, which is very prevalent in geriatric populations, is one of the main risk factors for the onset of frailty.A good nutritional status and, wherever necessary, supplementation with macronutrients and micronutrients reduce the risk of developing frailty. Physical exercise has been shown to improve functional status, helps to prevent frailty and is an effective treatment to reverse it. Despite the relatively large number of studies included, this review has some limitations. Firstly, variability in the design of the studies and their different aims reduce their comparability. Secondly, several of the studies did not adequately define frailty.ConclusionsPoor nutritional status is associated with the onset of frailty. Screening and early diagnosis of malnutrition and frailty in elderly people will help to prevent the onset of disability. Effective treatment is based on correction of the macro- and micronutrient deficit and physical exercise.     

Using mobile phones in healthcare management for the elderly

The increasing average life expectancy is simultaneously increasing the incidence of chronic diseases and the number of healthy elderly people, consequently leading to an increased demand for healthcare management methods that do not involve hospital visits. The development of health management services involving mobile phones will change the focus of medical services from hospital visits and treatments to managing the health decisions made by individuals in their daily lives. However, the elderly may experience specific difficulties in adapting to constantly evolving services.     

Cleft palate,hypotelorism, and hypospadias: Schilbach-Rott syndrome

A mother and two sons have cleft palate and facial appearance closely resembling cases described by Schilbach and Rott in 1988. One of the two males has hypospadias and learning disability and, like his mother, is of short stature. The family described by Schilbach and Rott also supports an autosomal dominant inheritance pattern.     

Interpreting routine biochemistry in those aged over 65 years: A time for change

In clinical practice, routine biochemistry tests are often performed for diagnostic or screening purposes. We reviewed papers that have reported reference values for people older than 65 years with or without overt health problems. Wider intervals have generally been reported for sodium, potassium, calcium and C-reactive protein (CRP) in the elderly. Higher levels of creatinine and lower levels of total cholesterol (TC) and serum albumin (SA) are observed with ageing. Elderly people have been found to be at greater risk for overt abnormalities in sodium, potassium, creatinine, TC, SA and CRP. The consequences of these abnormalities could be severe. For instance, even mild hyponatremia was associated with increased risk of mortality, disability and myocardial infarction. Mild hypernatremia was associated with severe disability. Mild increases in CRP levels were associated with an increased risk of sarcopenia, disability, cardiovascular disease and cognitive decline. Mild decreases in TC levels were associated with an increased risk of disability or mortality, and mild decreases in SA were associated with an increased risk of mortality, disability, sarcopenia and frailty. Nutritional factors could not wholly explain these effects. Modified biochemical reference values are required for elderly patients, as biochemical results can serve as markers of vulnerability to age-related diseases, linked to metabolism. Careful diagnosis and corrective interventions are needed for patients in this age group.     

A research agenda for ageing in China in the 21st century (2nd edition): Focusing on basic and translational research,long-term care,policy and social networks

One of the key issues facing public healthcare is the global trend of an increasingly ageing society which continues to present policy makers and caregivers with formidable healthcare and socio-economic challenges. Ageing is the primary contributor to a broad spectrum of chronic disorders all associated with a lower quality of life in the elderly. In 2019, the Chinese population constituted 18 % of the world population, with 164.5 million Chinese citizens aged 65 and above (65+), and 26 million aged 80 or above (80+). China has become an ageing society, and as it continues to age it will continue to exacerbate the burden borne by current family and public healthcare systems. Major healthcare challenges involved with caring for the elderly in China include the management of chronic non-communicable diseases (CNCDs), physical frailty, neurodegenerative diseases, cardiovascular diseases, with emerging challenges such as providing sufficient dental care, combating the rising prevalence of sexually transmitted diseases among nursing home communities, providing support for increased incidences of immune diseases, and the growing necessity to provide palliative care for the elderly. At the governmental level, it is necessary to make long-term strategic plans to respond to the pressures of an ageing society, especially to establish a nationwide, affordable, annual health check system to facilitate early diagnosis and provide access to affordable treatments. China has begun work on several activities to address these issues including the recent completion of the of the Ten-year Health-Care Reform project, the implementation of the Healthy China 2030 Action Plan, and the opening of the National Clinical Research Center for Geriatric Disorders. There are also societal challenges, namely the shift from an extended family system in which the younger provide home care for their elderly family members, to the current trend in which young people are increasingly migrating towards major cities for work, increasing reliance on nursing homes to compensate, especially following the outcomes of the ‘one child policy’ and the ‘empty-nest elderly’ phenomenon. At the individual level, it is important to provide avenues for people to seek and improve their own knowledge of health and disease, to encourage them to seek medical check-ups to prevent/manage illness, and to find ways to promote modifiable health-related behaviors (social activity, exercise, healthy diets, reasonable diet supplements) to enable healthier, happier, longer, and more productive lives in the elderly. Finally, at the technological or treatment level, there is a focus on modern technologies to counteract the negative effects of ageing. Researchers are striving to produce drugs that can mimic the effects of ‘exercising more, eating less’, while other anti-ageing molecules from molecular gerontologists could help to improve ‘healthspan’ in the elderly. Machine learning, ‘Big Data’, and other novel technologies can also be used to monitor disease patterns at the population level and may be used to inform policy design in the future. Collectively, synergies across disciplines on policies, geriatric care, drug development, personal awareness, the use of big data, machine learning and personalized medicine will transform China into a country that enables the most for its elderly, maximizing and celebrating their longevity in the coming decades. This is the 2nd edition of the review paper (Fang EF et al., Ageing Re. Rev. 2015).     

The concept of the disability process.

The accident process, by which excessive stress, tension, and denied dependency needs are transformed by an accident or illness into an “acceptable” disability is described, along with a graphic summary of the disability process. Suggestions are given for preventing or minimizing such disability states.     

Cleft palate,hypotelorism, and hypospadias: Schilbach‐Rott syndrome

A mother and two sons have cleft palate and facial appearance closely resembling cases described by Schilbach and Rott in 1988 . One of the two males has hypospadias and learning disability and, like his mother, is of short stature. The family described by Schilbach and Rott also supports an autosomal dominant inheritance pattern. © 2002 Wiley‐Liss, Inc.     

Does sleep disturbance predict depression in elderly people? A study in inner London.

Insomnia in elderly people has traditionally been regarded as inevitable and trivial. A longitudinal study was undertaken to examine the prevalence of sleep disturbance among elderly people in an inner London community and its association with demographic variables, depression, dementia and disability. Those aged 65 years and over living at home were interviewed using a validated and reliable semi-structured interview schedule. A total of 705 people were interviewed in 1987-88 and 524 were re-interviewed in 1990. Subjective sleep disturbance was found to be common (33% and 43%, respectively). Sleep disturbance was associated with being a woman, being unmarried, living alone, disability, and current and future depression, but not with dementia or older age. The best predictor of future depression in elderly people who were not depressed was current sleep disturbance. In the presence of current sleep disturbance, the traditional predictors of depression--being a woman, having a disability, being unmarried, living alone and being older--did not contribute further. This study has shown that sleep disorder is associated with pathology. Insomnia in elderly people requires assessment and this must be accompanied by the treatment of underlying disorders and monitoring of future health.     

Correlates of symptomatic, minor and major depression in the elderly

BACKGROUND: Associations between different types of depression with clinical characteristics and putative vulnerability factors from several domains (health, disability, personality, familial psychopathology) were studied in a sample of elderly subjects, in order to find arguments that support or discard the notion of discontinuity in correlates of depression. METHODS: Subjects were 183 depressed elderly persons from the general population, general practitioners and mental health care outpatient clinics, and a random elderly control group (n=74). Depression was subdivided into symptomatic (n=45), DSM-IV minor (n=73), and DSM-IV major (n=65) depression. The groups were compared with respect to a variety of variables from different domains. RESULTS: Most variables showed a marked difference between the control group and the depressive groups, and smaller or no differences between depressive subtypes. Limitations: The data were collected cross-sectionally. CONCLUSIONS: With a few notable exceptions, all subtypes of depression were significantly different from the control group, while differences between depressive subtypes were generally smaller. Depressive subtypes showed no discontinuum with respect to the associated variables. Similar associations in different subtypes of depression may indicate common vulnerability factors.     

Sounding Board. The illness as the focus of geriatric medicine

Understanding the difference between illness and disease is a prerequisite to the care of patients affected by incurable disorders. Educated palliation in the absence of substantive information regarding this discrepancy is the art of medicine. Because elderly patients often present with several chronic diseases, many of which are irreversible, cure-oriented physicians caring for the elderly are especially vulnerable to frequent disappointments. Multiple influences, such as psychological, social, environmental, and iatrogenous factors, may also substantially limit the possibilities for "total cure." More important, even though many chronic conditions are incurable, the discomfort or disability they produce may be substantially modified. If this concept is not realized and addressed, patients (many of them elderly) with irreversible chronic diseases may receive less than optimal care from physicians seeking cures. Studies need to be directed at defining and quantifying specific interactions between illness and disease and discovering risk factors for chronic disability in the elderly. The degree to which we as physicians can assist the chronically ill may reflect our understanding of human discomfort and our sensitivity to personal distress. If we maintain a purely disease-specific focus, we may have difficulty thinking about strategies to serve the patient. Defining pathologic entities may be less complicated than intervening in the illness of the patient, but the latter constitutes healing.     

Genetics,mental retardation,and the forging of new alliances

The lives of people with intellectual disabilities are tightly intermeshed with the philosophies and practices of special educators, therapists, psychologists, social workers, and others who make up the mental retardation field. These nonmedical workers represent a kind of extended family, which can strongly influence the decisions made and services received by the people they serve. By contrast, most individuals with mental retardation do not have extraordinary medical needs, and healthcare professionals play only a minor role in their human services family. There are deeply rooted historical differences between the medical model of mental retardation with which genetics professionals are familiar and the philosophies embraced by nonmedical workers who dominate the mental retardation field. These contrasts have an important impact on the genetic diagnostic process, as well as a more global effect on mental retardation research. Without the full participation of teachers, therapists, psychologists, and others outside the medical setting, many practical applications of genetic research can neither be implemented nor expanded upon, and an important opportunity for cross-fertilization is lost. It is in the interest of the genetics community to take advantage of recent overtures by the mental retardation field to forge new alliances and broaden its perspectives on intellectual disability.     

Validation of a new technique to detect malingering of cognitive symptoms: the b Test.

We administered the b Test, a new measure to identify malingering requiring recognition of overlearned information, to 34 suspected malingerers and to 161 subjects in various clinical groups (moderate to severe head injury, elderly depressed, learning disability, schizophrenia, right and left CVA, and elderly normals). Comparisons of groups revealed more commission and omission errors in the suspected malingerers relative to all groups except the right stroke patients. In addition, suspected malingerers took longer to complete the task than all groups except right and left stroke patients and normal elderly. A cutoff of >2 commission errors produced a sensitivity of 76.5% and specificity for all comparison groups combined of 82.6%. Lower sensitivity rates were documented for omissions (58.8 using cutoff of >40) and time (57.6% using cutoff of >12 minutes), but specificity remained high at 85.1% and 83.9%, respectively. Thus, the b Test shows considerable potential as a malingering detection tool.