Hospitalization and development of dependence in activities of daily living in a cohort of disabled older women: the Women's Health and Aging Study I

BACKGROUND: Changes in self-reported function in older adults are known to occur in the 2 weeks prior to, during, and in the first few months after hospitalization. The long-term outcome of hospitalization on functional status in disabled older adults is not known. The objective of this study was to determine whether hospitalization predicts long-term Activities of Daily Living (ADL) dependence in previously ADL independent, although disabled, older women. METHODS: The Women's Health and Aging Study I is a population-based, prospective cohort study of disabled, community-dwelling women > or =65 years old. We evaluated participants who were independent in ADLs at baseline and excluded women with incident stroke, lower extremity joint surgery, amputation, or hip fracture. We examined the association between self-reported incident hospitalization at three consecutive 6-month intervals and incident dependence in at least one ADL at 18 months (n = 595). RESULTS: Of 595 women evaluated, 32% had at least one hospitalization. Women who were hospitalized were more likely to become dependent in ADLs than were women who were not hospitalized (17% vs 8%, p =.001). In a multivariate model, hospitalization was independently predictive of development of ADL dependence that persisted at 18 months after baseline (odds ratio [OR], 3.2; 95% confidence interval [CI], 1.7-5.8), adjusting for age, race, education, baseline walking speed, difficulty with ADLs, self-reported health status, depressive symptoms, cognitive status, and presence of congestive heart failure, diabetes, or pulmonary disease. Increasing numbers of 6-month intervals with hospitalizations were independently predictive of higher risk in an adjusted model: one (OR, 2.3; 95% CI, 1.1-4.6), two (OR, 5.8; 95% CI, 2.4-14.4), and three (OR, 12.5; 95% CI, 2.7-57.6). CONCLUSIONS: These results suggest that hospitalization has an independent and dose-response effect on loss of ADL independence in disabled older women over an 18-month period.     

Anemia and recovery from disability in activities of daily living in hospitalized older persons

OBJECTIVES: To evaluate the predictive value of hemoglobin levels upon hospital admission on recovery from activity of daily living (ADL) disability during hospital stay in older patients. DESIGN: Longitudinal observational study. SETTING: Geriatric and internal medicine acute care units. PARTICIPANTS: Data are from 5,675 patients aged 65 and older enrolled in the Italian Group of Pharmacoepidemiology in the Elderly Study with ADL disability upon hospital admission. MEASUREMENTS: ADL disability was defined as inability to perform or need for assistance in performing one or more ADLs. Recovery from ADL disability was defined as independence in ADLs upon hospital discharge. Anemia was defined according to the World Health Organization criteria. Sociodemographic and clinical characteristics were considered as potential confounders. RESULTS: Mean age was 80.5 years; 57.7% of subjects were female. Prevalence of anemia was 46.8%. A total of 536 (9.4%) participants regained independence in all six ADLs at hospital discharge. Patients with anemia had a lower rate of recovery from ADL disability than those with normal hemoglobin levels (7.0% vs 11.6%; P<.001). Adjusted analyses confirmed that anemia was inversely associated with the likelihood of ADL recovery (odds ratio=0.71, 95% confidence interval=0.57-0.88). The probability of ADL recovery in anemic patients was higher at higher hemoglobin concentrations. CONCLUSION: In older hospitalized patients, anemia is inversely associated with the likelihood of regaining ADL independence during a hospital stay.     

Low micronutrient levels as a predictor of incident disability in older women

BACKGROUND: The role of nutritional status in the disablement process is still unclear. The objective of this study was to assess whether low concentrations of nutrients predict the development and course of disability. METHODS: Longitudinal study including community-dwelling women 65 years or older enrolled in the Women's Health and Aging Study I. In total, 643 women were assessed prospectively at 6-month intervals from 1992 to 1995. RESULTS: Incidence rates of disability in activities of daily living (ADLs) during 3 years of follow-up. Incidence rates in the lowest quartile of each selected nutrient were compared with those in the upper quartiles. The hazard ratios were estimated from Cox models adjusted for potential confounders. Women in the lowest quartile of serum concentrations of vitamin B(6) (hazard ratio [HR], 1.31; 95% confidence interval [CI], 1.03-1.67), vitamin B(12) (HR, 1.40; 95% CI, 1.12-1.74), and selenium (HR, 1.38; 95% CI, 1.12-1.71) had significantly higher risk of disability in ADLs during 3 years of follow-up compared with women in the upper 3 quartiles. CONCLUSIONS: Low serum concentrations of vitamins B(6) and B(12) and selenium predict subsequent disability in ADLs in older women living in the community. Nutritional status is one of the key factors to be considered in the development of strategies aimed at preventing or delaying the disablement process.     

Activity of daily living staging, chronic health conditions, and perceived lack of home accessibility features for elderly people living in the community

OBJECTIVE: 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. DESIGN: Cross‐sectional. SETTING: Community. PARTICIPANTS: Nine thousand four hundred forty‐seven community‐dwelling persons interviewed through the Second Longitudinal Study of Aging (LSOA II). MEASUREMENTS: Six ADLs organized into five stages ranging from no difficulty (0) to unable (IV). RESULTS: 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. CONCLUSIONS: 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.     

Patterns of onset of disability in activities of daily living with age

OBJECTIVES: To investigate the order in which activities of daily living (ADLs) are lost and whether the order is invariant between the sexes and age groups. DESIGN: Longitudinal data from the first five rounds of a routine health assessment by a nurse in participant's own home. SETTING: One large UK general practice with a list size of 32,500. PARTICIPANTS: Patients registered with the practice and age 75 and older. MEASUREMENTS: Disability was measured by self-report of performance in seven ADLs: mobility around the home, getting to and from the toilet, transfer from chair, transfer from bed, feeding, dressing, and bathing. Disability in each ADL was classified as being independent but having difficulty, using aids or help, or being unable to perform. Age at onset of disability in each ADL was calculated and analyzed using Kaplan-Meier plots and Cox regression models. Subjects who had died or remained independent by their last assessment were not included. RESULTS: The mean times between health assessments was approximately 20 months but with substantial variability both within and between individuals. A total of 1,344 people reported no difficulty in any ADL initially and 47.6% (640) subsequently reported disability. The order of activity restriction was bathing, mobility, toileting, dressing, transfers from bed and chair, and feeding. Women had a higher risk of disability in bathing (relative risk (RR) = 1.6, 95% confidence interval (CI) 1.3-1.9, P < .001) and toileting (RR = 1.7, 95% CI 1.2-2.5, P = .003), while for all ADLs there was a significant increase in the risk of disability with increasing age. The order of onset of disability for ADLs was invariant across sex and age groups. CONCLUSION: Lower-extremity strength (bathing, mobility, toileting) appears to be lost in older people before upper-extremity strength (dressing, feeding). Further work is now needed to develop prevention strategies to delay the onset of these disabilities.     

Depression and functional recovery after a disabling hospitalization in older persons

OBJECTIVES: To determine the association between depression and functional recovery in community‐living older persons who had a decline in function after an acute hospital admission. DESIGN: Prospective cohort study. SETTING: General community in greater New Haven, Connecticut, from March 1998 to December 2008. PARTICIPANTS: Seven hundred fifty‐four persons aged 70 and older. MEASUREMENTS: 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‐Depression Scale (CES‐D). Functional recovery was defined as returning to the community within 6 months at or above the prehospital level of ADL function and mobility. RESULTS: A decline in ADL function and mobility was observed after 42% and 41% of the hospitalizations, respectively. After controlling for several potential confounders, clinically significant depressive symptoms (CES‐D score ≥20) was associated with a lower likelihood of recovering mobility function (hazard ratio (HR)=0.79, 95% confidence interval (CI)=0.63–0.98) but not ADL function (HR=0.91, 95% CI=0.75–1.10) within 6 months of hospitalization. CONCLUSION: After a disabling hospitalization, community‐living older persons with preexisting depression may be less likely to recover their prehospitalization level of mobility function but not ADL function, although the reasons remain to be elucidated.     

Cognitive impairment,depressive symptoms,and functional decline in older people

OBJECTIVES: Although cognitive impairment and depressive symptoms are associated with functional decline, it is not understood how these risk factors act together to affect the risk of functional decline. The purpose of this study is to determine the relative contributions of cognitive impairment and depressive symptoms on decline in activity of daily living (ADL) function over 2 years in an older cohort. DESIGN: Prospective cohort study. SETTING: A U.S. national prospective cohort study of older people, Asset and Health Dynamics in the Oldest Old. PARTICIPANTS: Five thousand six hundred ninety-seven participants (mean age 77, 64% women, 86% white) followed from 1993 to 1995. MEASUREMENTS: Cognitive impairment and depressive symptoms were defined as the poorest scores: 1.5 standard deviations below the mean on a cognitive scale or 1.5 standard deviations above the mean on validated depression scales. Risk of functional decline in participants with depressive symptoms, cognitive impairment, and both, compared with neither risk factor, were calculated and stratified by baseline dependence. Analyses were adjusted for demographics and comorbidity. RESULTS: Eight percent (n = 450) of subjects declined in ADL function. In participants who were independent in all ADLs at baseline, the relative risk (RR) of 2-year functional decline was 2.3 (95% confidence interval (CI) = 1.7-3.1) for participants with cognitive impairment, 1.9 (95% CI = 1.3-2.6) for participants with depressive symptoms, and 2.4 (95% CI = 1.4-3.7) for participants with cognitive impairment and depressive symptoms. In participants who were dependent in one or more ADLs at baseline, RR of 2-year functional decline was 1.9 (95% CI = 1.2-2.8) for participants with cognitive impairment, 0.6 (95% CI = 0.3-1.3) for participants with depressive symptoms, and 1.5 (95% CI = 0.8-2.6) for participants with cognitive impairment and depressive symptoms. CONCLUSIONS: In participants with no ADL dependence at baseline, cognitive impairment and depressive symptoms are risk factors for decline, but that, in participants with dependence in ADL at baseline, cognitive impairment, but not depressive symptoms, is a risk factor for additional decline.     

Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: increased vulnerability with age

OBJECTIVES: To describe the changes in activities of daily living (ADL) function occurring before and after hospital admission in older people hospitalized with medical illness and to assess the effect of age on loss of ADL function. DESIGN: Prospective observational study. SETTING: The general medical service of two hospitals. PARTICIPANTS: Two thousand two hundred ninety-three patients aged 70 and older (mean age 80, 64% women, 24% nonwhite). MEASUREMENTS: At the time of hospital admission, patients or their surrogates were interviewed about their independence in five ADLs (bathing, dressing, eating, transferring, and toileting) 2 weeks before admission (baseline) and at admission. Subjects were interviewed about ADL function at discharge. Outcome measures included functional decline between baseline and discharge and functional changes between baseline and admission and between admission and discharge. RESULTS: Thirty-five percent of patients declined in ADL function between baseline and discharge. This included the 23% of patients who declined between baseline and admission and failed to recover to baseline function between admission and discharge and the 12% of patients who did not decline between baseline and admission but declined between hospital admission and discharge. Twenty percent of patients declined between baseline and admission but recovered to baseline function between admission and discharge. The frequency of ADL decline between baseline and discharge varied markedly with age (23%, 28%, 38%, 50%, and 63% in patients aged 70-74, 75-79, 80-84, 85-89, and > or =90, respectively, P <.001). After adjustment for potential confounders, age was not associated with ADL decline before hospitalization (odds ratio (OR) for patients aged > or =90 compared with patients aged 70-74 = 1.26, 95% confidence interval (CI) = 0.88-1.82). In contrast, age was associated with the failure to recover ADL function during hospitalization in patients who declined before admission (OR for patients aged > or =90 compared with patients aged 70-74 = 2.09, 95% CI = 1.20-3.65) and with new losses of ADL function during hospitalization in patients who did not decline before admission (OR for patients aged > or =90 compared with patients aged 70-74 = 3.43, 95% CI = 1.92-6.12). CONCLUSION: Many hospitalized older people are discharged with ADL function that is worse than their baseline function. The oldest patients are at particularly high risk of poor functional outcomes because they are less likely to recover ADL function lost before admission and more likely to develop new functional deficits during hospitalization     

Total serum cholesterol and recovery from disability among hospitalized older adults

BACKGROUND: The association between total serum cholesterol and health outcomes among older adults is controversial. The objective of the present study was to determine within a cohort of acutely hospitalized disabled elderly patients whether total cholesterol predicts recovery from disability in basic activities of daily living (ADL). METHODS: Patients (3150) 65 years old or older admitted to 81 acute care units in Italy and presenting with ADL disability at hospital admission were included in this study. ADL disability was defined as need of assistance or total dependence in one or more ADLs (eating, dressing, personal hygiene, transferring, and toilet use). Recovery was defined as no disability at hospital discharge in any of the five ADLs considered. RESULTS: Mean age of study participants was 80.5 +/- 7.2 years, and 1305 (41.1%) were men. The rate of recovery from ADL disability was 14.5% for participants with total cholesterol < 200 mg/dL (n = 306/2108), 20.2% for those with total cholesterol between 200 and 239 mg/dL (n = 144/713), and 23.1% for those with total cholesterol > or = 240 mg/dL (n = 76/329). After adjustment for potential confounders, relative to that of patients with cholesterol < 200 mg/dL, risk ratios for recovery were 1.31 for participants with cholesterol between 200 and 239 mg/dL (95% confidence interval [CI], 1.07-1.62) and 1.36 (95% CI, 1.04-1.79) for those with cholesterol > or = 240 mg/dL. After exclusion of 769 patients with total cholesterol < 145 mg/dL, the risk ratios (compared with those for participants with cholesterol < 200 mg/dL) for recovery were 1.33 (95% CI, 1.07-1.66) for participants with cholesterol between 200 and 239 mg/dL and 1.41 (95% CI, 1.06-1.88) for patients with cholesterol > or = 240 mg/dL. CONCLUSIONS: Among hospitalized disabled older adults, elevated levels of cholesterol are associated with increased rate of recovery from ADL disability.     

Outcome and utilization differences for older persons with stroke in HMO and fee-for-service systems

OBJECTIVES: To compare treatment and outcomes for older persons with stroke in Medicare health maintenance organizations (HMOs) and fee-for-service (FFS) systems. DESIGN: Inception cohort stratified by payer and followed for 1 year. SETTING: Six HMOs and five FFS systems with large Medicare populations in the West, Midwest, and Eastern United States. PARTICIPANTS: A total of 429 randomly selected stroke patients receiving rehabilitation in nursing homes or rehabilitation hospitals (RHs) from June 1993 to June 1995. MEASUREMENTS: Improvement in activities of daily living (ADLs) during rehabilitation, and ADL recovery, community residence, and utilization until 12 months after stroke. Outcomes were adjusted for premorbid function, marital status, comorbid illness, posthospital function, cognition, psychological problems, and stroke deficits. RESULTS: At baseline, HMO patients were more likely to be married, and less likely to be blind or have psychiatric diagnoses. HMO patients had shorter hospitalizations (P < .001), were less likely to be admitted to RHs (13% vs 85%, P < .001), and received fewer therapy and physician specialist visits (P < .001) but more home health visits (P < .001). During rehabilitation, FFS patients made greater improvement in ADLs (difference, 0.73 ADLs; 95% CI, .37-1.09). At 1 year, there was no difference in ADL recovery (difference, -0.24 ADL; 95% CI, -0.64-0.16), but FFS patients were more likely to reside in the community (adjusted OR, 1.8; 95% CI, 1.1-3.1), and HMO patients were more likely to reside in nursing homes (adjusted OR, 2.4; 95% CI, 1.1-5.5). CONCLUSION: Study findings suggest that short-term functional outcomes and eventual community residence rates are poorer for Medicare HMO patients with stroke than for stroke patients receiving FFS care, consistent with the lower intensity of rehabilitation (in nursing homes vs RHs) and less specialty physician care.     

Depressive symptoms, chronic diseases, and physical disabilities as predictors of cognitive functioning trajectories in older Americans

OBJECTIVES: To determine the concurrent influence of depressive symptoms, medical conditions, and disabilities in activities of daily living (ADLs) on rates of decline in cognitive function of older Americans. DESIGN: Prospective cohort. SETTING: National population based. PARTICIPANTS: A national sample of 6,476 adults born before 1924. MEASUREMENTS: Differences in cognitive function trajectories were determined according to prevalence and incidence of depressive symptoms, chronic diseases, and ADL disabilities. Cognitive performance was tested five times between 1993 and 2002 using a multifaceted inventory examined as a global measure (range 0–35, standard deviation (SD) 6.0) and word recall (range 0–20, SD 3.8) analyzed separately. RESULTS: Baseline prevalence of depressive symptoms, stroke, and ADL limitations were independently and strongly associated with lower baseline cognition scores but did not predict future cognitive decline. Each incident depressive symptom was independently associated with a 0.06‐point lower (95% confidence interval (CI)=0.02–0.10) recall score, incident stroke with a 0.59‐point lower total score (95% CI=0.20–0.98), each new basic ADL limitation with a 0.07‐point lower recall score (95% CI=0.01–0.14) and a 0.16‐point lower total score (95% CI=0.07–0.25), and each incident instrumental ADL limitation with a 0.20‐point lower recall score (95% CI=0.10–0.30) and a 0.52‐point lower total score (95% CI=0.37–0.67). CONCLUSION: Prevalent and incident depressive symptoms, stroke, and ADL disabilities contribute independently to poorer cognitive functioning in older Americans but do not appear to influence rates of future cognitive decline. Prevention, early identification, and aggressive treatment of these conditions may ameliorate the burdens of cognitive impairment.     

Risk factors for lack of recovery of ADL independence after hospital discharge

OBJECTIVE: To determine risk factors for lack of recovery of independent functioning after hospitalization for acute medical illness. DESIGN: Secondary analysis of cohort study of patients receiving home nursing after discharge. SETTING: Evaluations performed in the home after discharge and 1 month later. PARTICIPANTS: A total of 73 adults aged 65 years and older who were independent in activities of daily living (ADLs) before hospitalization and dependent at discharge. MEASUREMENTS: Self-report and objective measures of function, mobility, and cognition. OUTCOME: Return to independence in ADLs 1 month after discharge. RESULTS: Fifty-nine percent of patients did not return to previous ADL independence by 1 month postdischarge. The likelihood for not recovering was 87% (95% CI, 70-100%) if a patient had a Mini-Mental State Examination score (MMSE) < 24 at discharge (P = .015). Among patients with good cognition, 85% (95% CI, 66-100%) of those who used an assistive device indoors before hospitalization did not recover (P = .007). Among patients with good cognition and no previous assistive device use, 73% (95% CI, 47-99%) of those with a Timed "Up and Go" of > or = 40 seconds did not recover (P = .012). The likelihood of recovery was high (76%, 95% CI 56-96%) if a patient had no assistive device prehospital, a good MMSE, and a Timed "Up and Go" of < 20 seconds. CONCLUSION: We hypothesize that a classification strategy using cognition, prehospital mobility, and discharge physical performance will predict patients who are less likely to recover functional independence after hospitalization. If this is validated in future study, it may help clinicians identify patients who are more likely to benefit from additional intervention.     

Unmet need for personal assistance with activities of daily living among older adults

PURPOSE: This study examined the prevalence, correlates, and negative consequences of unmet need for personal assistance with activities of daily living (ADLs) among older adults. DESIGN AND METHODS: The authors analyzed cross-sectional data from the 1994 National Health Interview Survey's Supplement on Aging. Data were weighted to be representative of the noninstitutionalized population aged 70 years and older. RESULTS: Overall, 20.7% of those needing help to perform 1 or more ADLs (an estimated 629,000 persons) reported receiving inadequate assistance; for individual ADLs, the prevalence of unmet need ranged from 10.2% (eating) to 20.1% (transferring). The likelihood of having 1 or more unmet needs was associated with lower household income, multiple ADL difficulties, and living alone. Nearly half of those with unmet needs reported experiencing a negative consequence (e.g., unable to eat when hungry) as a result of their unmet need. IMPLICATIONS: Greater, targeted efforts are needed to reduce the prevalence and consequences of unmet need for ADL assistance in elderly persons.     

Problems of older adults living alone after hospitalization

OBJECTIVE: To describe functional deficits among older adults living alone and receiving home nursing following medical hospitalization, and the association of living alone with lack of functional improvement and nursing home utilization 1 month after hospitalization. DESIGN: Secondary analysis of a prospective cohort study. PARTICIPANTS: Consecutive sample of patients age 65 and over receiving home nursing following medical hospitalization. Patients were excluded for new diagnosis of myocardial infarction or stroke in the previous 2 months, diagnosis of dementia if living alone, or nonambulatory status. Of 613 patients invited to participate, 312 agreed. MEASUREMENTS: One week after hospitalization, patients were assessed in the home for demographic information, medications, cognition, and self-report of prehospital and current mobility and function in activities of daily living (ADLs) and independent activities of daily living (IADLs). One month later, patients were asked about current function and nursing home utilization. The outcomes were lack of improvement in ADL function and nursing home utilization 1 month after hospitalization. RESULTS: One hundred forty-one (45%) patients lived alone. After hospital discharge, 40% of those living alone and 62% of those living with others had at least 1 ADL dependency (P=.0001). Patients who were ADL-dependent and lived alone were 3.3 (95% confidence interval [95% CI], 1.4 to 7.6) times less likely to improve in ADLs and 3.5 (95% CI, 1.0 to 11.9) times more likely to be admitted to a nursing home in the month after hospitalization. CONCLUSION: Patients who live alone and receive home nursing after hospitalization are less likely to improve in function and more likely to be admitted to a nursing home, compared with those who live with others. More intensive resources may be required to continue community living and maximize independence. This work was supported by grants from the American Physical Therapy Foundation, the Dean Foundation, and the University of Wisconsin Medical School and Graduate School. Dr. Mahoney was the recipient of a Clinical Investigator Award from the NIA (K08AG00623).     

Effect of arthritis in middle age on older-age functioning

OBJECTIVES: 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.
DESIGN: Prospective longitudinal study.
SETTING: The Health and Retirement Study, a nationally representative sample of persons aged 50 to 62 at baseline who were followed for 10 years.
PARTICIPANTS: Seven thousand five hundred forty-three subjects with no difficulty in mobility or ADL function at baseline.
MEASUREMENTS: 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 comorbid conditions, body mass index, exercise, and demographic characteristics.
RESULTS: 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).
CONCLUSION: 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.     

Executive function, more than global cognition, predicts functional decline and mortality in elderly women

BACKGROUND: Functional impairment in community-dwelling older adults is common and is associated with poor outcomes. Our goal was to compare the contribution of impairment in executive function or global cognitive function to predicting functional decline and mortality. METHODS: We studied 7717 elderly women enrolled in a prospective study (mean age 73.3 years) and identified women with poor baseline executive function (score > 1 standard deviation [SD] below the mean on the Trail Making Test B (Trails B; n = 957, 12.4%), poor global cognitive function (score > 1 SD below the mean on a modified Mini-Mental State Examination [mMMSE], n = 387, 5.0%), impairment in both (n = 249, 3.2%), or no impairment (n = 6124, 79.4%). We compared level of functional difficulty (Activities of Daily Living [ADLs] and Instrumental ADLs [IADLs]) at baseline and at 6-year follow-up and survival at follow-up. We also determined if the association was independent of age, education, depression, medical comorbidities, and baseline functional ability. RESULTS: At baseline, women with Trails B impairment only or impairment on both tests reported the highest proportion of ADL and IADL dependence compared to the other groups. At the 6-year follow-up after adjusting for age, education, medical comorbidities, depression, and baseline ADL or IADL, women with only Trails B impairment were 1.3 times more likely to develop an incident ADL dependence (adjusted odds ratio [OR] = 1.34; 95% confidence interval [CI], 1.07-1.69) and 1.5 times more likely to develop a worsening of ADL dependence (adjusted OR = 1.48; 95% CI, 1.16-1.89) when compared to women with no impairment on either test. In addition, women with only Trails B impairment had a 1.5-fold increased risk of mortality (adjusted hazard ratio [HR] = 1.48; 95% CI, 1.21-1.81). In contrast, women with impairment on only mMMSE were not at increased risk to develop incident ADL or IADL dependence, a worsening of ADL or IADL dependence, or mortality. CONCLUSION: Compared to women with no impairment, women with executive function impairment had significantly worse ADL and IADL function cross-sectionally and over 6 years. Individuals with executive dysfunction also had increased risk of mortality. These results suggest that screening of executive function can help to identify women who are at risk for functional decline and decreased survival.     

Nutritional parameters, body composition, and progression of disability in older disabled residents living in nursing homes

BACKGROUND: The evaluation of nutritional status is one of the primary components of multidimensional geriatric assessment. We investigated the relationship between some markers of malnutrition and the modifications in functional status in a sample of older disabled residents living in nursing homes. METHODS: Ninety-eight subjects who were independent in at least two activities of daily living (ADLs) were enrolled in a 2-year longitudinal study. Anthropometric, nutritional, and metabolic parameters, as well as body composition, were measured at baseline and after 2 years. RESULTS: Deteriorating functional status (> or =2 additional lost ADLs) was associated with baseline albumin levels (Tertile 3 vs Tertile 1; odds ratio [OR] 0.16, 95% confidence interval [CI] 0.04-0.67) and subscapular skinfold thickness (Tertile 3 vs. Tertile 1; OR 0.06, 95% CI 0.006-0.50). After multivariate adjustment, the OR for increasing disability was >4 in subjects with decreasing body cell mass (BCM), compared with subjects with a stable BCM. The degree of BCM reduction was strongly related to the number of additional ADLs lost at follow-up (test for trend, p = .003). CONCLUSIONS: In a sample of older disabled nursing home residents, signs of malnutrition seem to predict further worsening in functional status. Furthermore, BCM declines proportionally to the loss in ADLs, suggesting the existence of a strong relationship between BCM loss and the progressive deterioration of functional status.     

Incidence of and predictors for chronic disability in activities of daily living among older people in Taiwan.

OBJECTIVES: To estimate the incidence of chronic activities of daily living (ADL) disability and to analyze the sociodemographic, health status, adverse lifestyle, and leisure-time physical activity predictors for chronic ADL disability. DESIGN: We recruited a cohort of community-dwelling older people in Taipei, Taiwan, who were not ADL disabled in August 1993, and we followed them until August 1996. SETTINGS AND PARTICIPANTS: The study subjects were 1321 community-dwelling people aged 65 years or older who were ADL intact at the initial interview in August 1993. The study sample was a subset of a probability sample (n = 1583) randomly selected from household registrations in the four districts of the Taipei metropolitan area. MEASUREMENTS: Baseline information regarding various factors potentially associated with the development of chronic ADL disability was assessed and collected at the beginning of the study. Study participants were assessed annually for ADL function by a structured home interview using a six-item scale. Participants who were unable to perform independently at least one of the six items--eating, bathing, dressing, toileting, transfers, and walking inside the house--for more than 3 months were considered chronically ADL disabled. Cox proportional hazard regression models were utilized to examine the independent effect of the potential predictors on risk of chronic ADL disability. RESULTS: During the 3-year study period, 145 (11.0%) participants developed chronic ADL disability, 58 (4.4%) participants were lost to follow-up, and 83 (6.3%) participants died. Multiple hazard regression analysis showed that individuals aged 70 to 79 years or older than age 80 had increased risk of ADL disability (relative risk: 2.05 (95% confidence interval (CI), 1.35-3.11) and 3.89 (95%CI, 2.33-6.50), respectively) compared with those participants younger than age 70. Risk of chronic ADL disability was inversely associated with routine exercise (RR = 0.52; 95% CI, 0.39-0.68). CONCLUSIONS: Age is the most significant predictor of chronic ADL disability. Lack of routine exercise is also a significant predictor of ADL disability in older adults.     

Persistent mobility deficit in the absence of deficits in activities of daily living: a risk factor for mortality

OBJECTIVES: To investigate the extent to which self-reported mobility deficit in the absence of impairment in activities of daily living (ADL) is associated with elevated mortality risk. DESIGN: Prospective cohort study, with annual assessments of mobility and ADL status and ongoing monitoring of vital status. SETTING: Population-based cohort drawn from Medicare enrollees in New York City. PARTICIPANTS: One thousand two hundred ninety-eight older adults reporting functional status at baseline (1992-1994) and 2 years later. MEASUREMENTS: Subjects reported mobility (e.g., walking, climbing stairs, and rising from a chair) and ADL (e.g., bathing, toilet use, dressing, grooming, and feeding) limitations. Two-year functional status trajectories were noted. We used two additional follow-up periods, at 2 and 4 years, to examine the likelihood that older people with mobility deficit may face an increased risk of death without first passing through a state of enduring ADL disability. RESULTS: At 2 years, 12.7% had incident mobility deficit without ADL disability, and 21.3% were persistently disabled in mobility without ADL disability. Relative to subjects free of disability at baseline and follow-up, risk of mortality in the incident mobility deficit group was elevated at 2 and 4 years but did not achieve statistical significance. By contrast, for subjects with persistent mobility impairment who did not report ADL impairment, the mortality risk was significantly elevated both at 2 years (relative risk (RR) = 2.5; 95% confidence interval (CI) = 1.1-5.7)) and 4 years (RR = 2.9; 95% CI = 1.7-4.9)) of follow-up. Mortality was significantly elevated in this group in analyses restricted to respondents with no or only one comorbid condition. CONCLUSION: Continuing, self-reported mobility impairment in the absence of ADL deficit is a risk factor for mortality. Older people with self-reported mobility deficit face an increased risk of mortality without first passing through enduring states of ADL disability.     

Predictors of functional disability with focus on activities of daily living: A community based follow-up study in older adults in India

BackgroundDisability in activities of daily living is a growing concern among older populations all over the world. India has one of the rapidly ageing populations and predicted burden of functional disability is higher for Indian older adults as compared to other ageing Asian countries.MethodsTotal 1140 aged 60 years and over participated in a baseline study. 560 of them participated in the prospective cohort study conducted in the city of Pune, India. An interview and functional assessment using a questionnaire and Pune-FAAT tool was carried out in 2013–14. Binary logistic regression was used to obtain the factors that increased the odds of having ADL disability at follow-up.ResultsThe mean age of the study population was 69.73 ± 5.48 years. Squatting, walking and climbing functions were affected significantly. Total 376 participants (67.1%) reported difficulties and/or disability in performing activities of daily living (ADL) at follow-up. Hospitalization (OR = 3.6; 95% CI: 1.9–6.7), being female (OR = 2.3; 95% CI: 1.5–3.5), presence of two or more chronic diseases (OR = 1.7; 95% CI: 1.1–2.7), experience of memory loss (OR = 1.9; 95% CI: 1.2–3.0) and feeling of loneliness (OR = 2.3; 95% CI: 1.0–5.3) increased the odds of being in the “With disability” group at follow-up. Apart from this, self-rated health and self-reported depression were associated with limitations in ADL.ConclusionHospitalization and being female appeared to be the most significant risk factors for disability in urban older adults in India. Rehabilitation services after hospitalization, physical exercise, effective control on chronic illness, and social participation to reduce loneliness is recommended.