Determinants of service use among the elderly: the Sydney Older Persons Study

Objectives: To examine the determinants of service use in a community dwelling sample aged 75 or over. Methods: Subjects (n = 537) were interviewed about use of community and medical services and the provision of unpaid support from their social network. Measures of disease and disability, detailed network support data and factors that may either enable or predispose subjects to service use were obtained and their prediction of service use examined. Results: Unpaid support and community service use were predicted predominantly by disability, with disease providing little additional prediction. Medical service use was predicted by both disease and disability. With disease and disability controlled for, other variables did not significantly predict medical service use or unpaid support; but did predict small additional variation in some community service use. Conclusions: Disability and disease are the major determinants of service use with other factors contributing to the use of some community services.     

Effect of Physical Activity Counseling on Disability in Older People: A 2‐Year Randomized Controlled Trial

OBJECTIVES: To study the effect of a physical activity counseling intervention on instrumental activity of daily living (IADL) disability. DESIGN: Primary care–based, single‐blind, randomized controlled trial. SETTING: City of Jyväskylä, central Finland. PARTICIPANTS: Six hundred thirty‐two people aged 75 to 81 who were able to walk 500 meters without assistance, were at most moderately physically active, had a Mini‐Mental State Examination score greater than 21, had no medical contraindications for physical activity, and gave informed consent for participation. INTERVENTION: A single individualized physical activity counseling session with supportive phone calls from a physiotherapist every 4 months for 2 years and annual lectures on physical activity. Control group received no intervention. MEASUREMENTS: The outcome was IADL disability defined as having difficulties in or inability to perform IADL tasks. Analyses were carried out according to baseline IADL disability, mobility limitation, and cognitive status. RESULTS: At the end of the follow‐up, IADL disability had increased in both groups (P<.001) and was lower in the intervention group, but the group‐by‐time interaction effect did not reach statistical significance. Subgroup analyses revealed that the intervention prevented incident disability in subjects without disability at baseline (risk ratio=0.68, 95% confidence interval=0.47–0.97) but had no effect on recovery from disability. CONCLUSION: The physical activity counseling intervention had no effect on older sedentary community‐dwelling persons with a wide range of IADL disability, although it prevented incident IADL disability. The results warrant further investigation to explore the benefits of a primary care–based physical activity counseling program on decreasing and postponing IADL disability.     

Relationship between body mass index and different domains of disability in older persons: the 3C study

OBJECTIVE: To study the relationships between body mass index (BMI) and different domains of disability in elderly subjects from the French 3C study. SETTING: Three cities in France: Bordeaux (South-West), Dijon (North-East) and Montpellier (South-East). DESIGN: Cross-sectional study. SUBJECTS: A sample of 8966 elderly community dwellers (age: 65-101 y). MEASUREMENTS: Main outcome measures: BMI, continence, basic and Instrumental Activities of Daily Living (ADL and IADL) and mobility. Adjustment variables: age, educational level, lifestyle, cognitive functioning, smoking and drinking history, depression, dyspnea, diabetes and indicator of cardiovascular disease. RESULTS: Obesity (BMI> or =30 kg/m2) was significantly associated with disability in each domain for women. The relationship tended to be linear for ADL and for continence; whereas for IADL, underweight women (BMI <21 kg/m2) were also at higher risk of disability. In men, relationships were weaker since BMI was only associated with mobility restriction, with a higher risk for both underweight and obese subjects. CONCLUSION: These results are in favor of a strong association between obesity and the three domains of disability and incontinence. Weaker relationships between underweight and disability were observed. Results suggest that maintaining a BMI in the healthy range could contribute to independence in activities of daily living.     

Chronic medical conditions as predictors of functional disability in an older population in Taiwan

Objective: As there is little understanding of disability processes in Taiwanese elders, the present study aimed to identify medical predictors of the incidence of activities of daily living (ADL) disability. Method: A total of 903 subjects were studied over a 4‐year period (1994–1998). The measurement instrument was the Chinese‐version Multidimensional Functional Assessment Questionnaire (CMFAQ). Only the subjects free of ADL disability at baseline were included in separate logistic regression models to predict disability in physical and instrumental ADL. Results: The hypothesised associations between chronic conditions and future functional disability were cross‐nationally confirmed. Arthritis, diabetes and hypertension were significantly predictive of the onset of physical ADL (PADL) disability; diabetes was the only medical predictor of instrumental ADL (IADL) disability. Age and educational level were significant predictors of PADL and IADL. Conclusions: Prevention programs for chronic disease need to pay more attention not only to the disabled population, but also to secondary prevention among those elders who have higher medical risk of developing disability.     

Ten-year change in disability prevalence and related factors in two generations of French elderly community dwellers: data from the PAQUID study

BACKGROUND AND AIMS: Some studies have reported a decline in disability prevalence in older people, but few data were available for Europe, especially for France. Our aim was to study the 10-year evolution of disability prevalence in elderly community dwellers and related factors. METHODS: Two generations of subjects aged 75 to 84, participants in the PAQUID (Personnes Agées QUID) cohort were compared. The first generation included 1496 subjects (born between 1903 and 1912) and the second 910 subjects (born between 1913 and 1922). Three domains of disability were assessed: mobility, Activities of Daily Living (ADL) and Instrumental ADL (IADL). Logistic regressions were used to explain the effect of generation on disability, controlling for sociodemographic characteristics, impairment, life-style, medical care, and social support. RESULTS: The percentage of subjects fully independent increased from 13.5 to 23.3% (p < 0.001). A large decline in disability prevalence independent of the controlled factors was observed for mobility in both genders [Odds Ratio for the second generation (OR(G2)) = 0.48, 95% CI 0.38-0.60]. When adjusting for age and education, the risk of IADL disability was significantly lower in women in the second generation (ORG2 0.61, 95% CI 0.49-0.77), and the generation effect was strengthened when adjusting for the other covariates, but unchanged in men (ORG2 1.09, 95% CI 0.81-1.48). There was no significant change for ADL. CONCLUSIONS: A significant decline in disability prevalence was observed over 10 years, which was not explained by the selected covariates. These aggregate changes differed by gender, education, and the domain of disability considered.     

Activity restriction induced by fear of falling and objective and subjective measures of physical function: a prospective cohort study

OBJECTIVES: To examine whether activity restriction specifically induced by fear of falling (FF) contributes to greater risk of disability and decline in physical function. DESIGN: Prospective cohort study. SETTING: Population‐based older cohort. PARTICIPANTS: Six hundred seventy‐three community‐living elderly (≥65) participants in the Invecchiare in Chianti Study who reported FF. MEASUREMENTS: FF, fear‐induced activity restriction, cognition, depressive symptoms, comorbidities, smoking history, and demographic factors were assessed at baseline. Disability in activities of daily living (ADLs) and instrumental activities of daily living (IADLs) and performance on the Short Performance Physical Battery (SPPB) were evaluated at baseline and at the 3‐year follow‐up. RESULTS: One‐quarter (25.5%) of participants did not report any activity restriction, 59.6% reported moderate activity restriction (restriction or avoidance of <3 activities), and 14.9% reported severe activity restriction (restriction or avoidance of ≥3 activities). The severe restriction group reported significantly higher IADL disability and worse SPPB scores than the no restriction and moderate restriction groups. Severe activity restriction was a significant independent predictor of worsening ADL disability and accelerated decline in lower extremity performance on SPPB over the 3‐year follow‐up. Severe and moderate activity restriction were independent predictors of worsening IADL disability. Results were consistent even after adjusting for multiple potential confounders. CONCLUSION: In an elderly population, activity restriction associated with FF is an independent predictor of decline in physical function. Future intervention studies in geriatric preventive care should directly address risk factors associated with FF and activity restriction to substantiate long‐term effects on physical abilities and autonomy of older persons.     

Prediction of functional disability by depressive state among community‐dwelling elderly in Japan: A prospective cohort study

Aim: We carried out a prospective cohort study to evaluate the risk factors of functional disability by depressive state. Methods: A total of 783 men and women, aged 70 years and over, participated in this study. We followed the participants in terms of the onset of functional disability by using a public long‐term care insurance database. The Geriatric Depression Scale (GDS) was used to measure depressive state. Age, sex, history of chronic disease, living alone, fall experience, cognitive impairment, instrumental activities of daily living (IADL), the Motor Fitness Scale (MFS), frequency of going out and social support at baseline were used as the main covariates. The Cox regression analysis was used to examine the difference in functional disability stratified according to depressive state. Results: The incidence of functional disability was 38 persons in the non‐depression group and 42 persons in the depression group (RR 2.34; 95% CI 1.46–3.79). The results of the depression group showed a significant difference in cognitive impairment (HR 3.51; 95% CI 1.39–8.85), MFS (HR 5.60; 95% CI 1.32–23.81) and IADL (HR 3.37; 95% CI 1.65–6.85). The results of the non‐depression group showed a significant difference in MFS (HR 2.97; 95% CI 1.47–6.96), and frequency of going out (HR 3.21; 95% CI 1.47–6.96). Conclusions: In conclusion, risk factors for functional disability were found to differ on the basis of whether or not community‐dwelling elderly individuals experience depressive state. The type of support offered must be based on whether or not depressive state is present. Geriatr Gerontol Int 2012; ??: ??–?? .     

Instrumental activities of daily living as a potential marker of frailty: a study of 7364 community-dwelling elderly women (the EPIDOS study).

BACKGROUND: A number of clinical conditions have been shown to be associated with frailty in elderly people. We hypothesized that incapacities on the Instrumental Activities of Daily Living (IADLs) scale could make it possible to identify this population. We investigated the associations between IADL incapacities and the various known correlates of frailty in a cohort of community-dwelling elderly women. METHODS: Cross-sectional analysis was carried out on the data from 7364 women aged over 75 years (EPIDOS Study). The IADL was the dependent variable. Sociodemographic, medical, and psychological performance measures were obtained during an assessment visit. Falls in the previous 6 months and fear of falling were also ascertained. Body composition was measured by dual-energy x-ray absorptiometry. The factors associated with disability in at least one IADL were included in a logistic regression model. RESULTS: Thirty-two percent of the population studied had disability in at least one IADL item. This group was significantly older (81.7 +/- 4.1 yr vs 79.8 +/- 3.4 yr), had more frequent histories of heart disease, stroke, depression or diabetes, and was socially less active (p =.001). These associations persisted after multivariate analysis. Cognitive impairment as assessed by the Pfeiffer test (Pfeiffer score <8) was closely associated with disabilities on the IADL (OR 3.101, 95% confidence interval [CI] 2.19-4.38). Falls and fear of falling were also more frequent in the group of women with an abnormal IADL (p =.001) but only fear of falling remained significantly associated with incapacities on at least one IADL item after logistic regression (OR 1.47, 95% CI 1.28-1.69). Women with disability on at least one IADL item also had lower bone mineral density, this was independent of the other factors. CONCLUSION: Our results confirmed that women with disability on at least one IADL item are frailer because they had more associated disorders, poorer cognitive function and more frequent falls. Disabilities on this scale could be a good tool for identifying individuals at risk of frailty among elderly persons living at home and in apparent good health. This finding requires confirmation by longitudinal studies.     

Predictive validity of the Brazilian version of the Tilburg Frailty Indicator for adverse health outcomes in older adults

PurposeThis study aimed to determine the predictive value of the Brazilian Tilburg Frailty Indicator (TFI) for adverse health outcomes (falls, hospitalization, disability and death), in a follow-up period of twelve months.MethodsThis longitudinal study was carried out with a sample of people using primary health care services in Rio de Janeiro, Brazil. At baseline the sample consisted of 963 people aged 60 years and older. A subset of all respondents participated again one year later (n = 640, 66.6% response rate). We used the TFI, the Katz’s scale for assessing ADL disability and the Lawton Scale for assessing IADL disability. Falls, hospitalization and death were also assessed using a questionnaire.ResultsThe prevalence of frailty was 44.2% and the mean score of the TFI was 4.4 (SD = 3.0). There was a higher risk of loss in functional capacity in ADL (OR = 3.03, CI95% 1.45–6.29) and in IADL (OR = 1.51, CI95% 1.05–2.17), falls (OR = 2.08, CI95% 1.21–3.58), hospitalization (OR = 1.83, CI95% 1.10–3.06), and death (HR = 2.73, CI95% 1.04–7.19) for frail when compared to non-frail elderly, in the bivariate analyses. Controlling for the sociodemographic variables, the frailty domains together improved the prediction of hospitalization, falls and loss in functional capacity in ADL, but not loss in functional capacity in IADL.ConclusionThe TFI is a good predictor of adverse health outcomes among elderly users of primary care services in Brazil and appears an adequate and easy to administer tool for monitoring their health conditions.     

Functional status and calcaneal quantitative ultrasound measurements among the oldest old people living in rural areas of Korea

The number of very elderly people is increasing worldwide, so that the prevention of fractures and disability in this frail population has become a growing concern. This study evaluated the association between functional status and bone health in the oldest old. The study participants were of a very elderly population comprising 170 rural community dwellers, aged 80-107 years. Quantitative ultrasound (QUS) measurements were performed on both heels. Functional status was assessed by evaluating activities of daily living (ADL) and instrumental activities of daily living (IADL). Data on sociodemographic characteristics and potential risk factors, including medical history, smoking, alcohol intake, exercise, and physical activities were collected by trained interviewers. Generalized multiple linear regression suggested that disability was significantly associated with calcaneal QUS in the oldest old. After adjusting for the effect of potential covariates, such as age, gender, education level, weight, smoking, and physical activity level, the lowest tertile score groups of ADL and IADL were associated with a decrease in stiffness index (SI) T-score of calcaneal QUS. A complete ADL deficit was associated with a low QUS (adjusted beta vs. independent group=-1.17, 95% confidence interval=-2.01 to -0.33). Evidence of disability as an associated factor on bone health provides important insight to devise strategies for preventing or delaying further disablement among the elderly.     

Use of unpaid and paid home care services among people with HIV infection in the USA

This paper examines utilization of paid and unpaid home health care using data from a nationally representative sample of HIV-positive persons receiving medical care in early 1996 (N = 2,864). Overall, 21.0% used any home care, 12.2% used paid care and 13.6% used unpaid care. Most (70.0%) users of home care received care from only one type of provider. Substantially more hours of unpaid than paid care were used. We also found evidence of a strong association between type of service used and type of care provider: 62.4% of persons who used nursing services only received paid care only; conversely, 55.5% of persons who used personal care services only received care only from unpaid caregivers. Use of home care overall was concentrated among persons with AIDS: 39.5% of persons with AIDS received any home health care, compared to 9.5% of those at earlier disease stages. In addition to having an AIDS diagnosis, logistic regression analyses indicated that other need variables significantly increased utilization; a higher number of HIV-related symptoms, lower physical functioning, less energy, a diagnosis of CMV and a recent hospitalization each independently increased the odds of overall home care utilization. Sociodemographic variables had generally weak relationships with overall home care utilization. Among users of home care, non-need variables had more influence on use of paid than unpaid care. Both paid and unpaid home health care is a key component of community-based systems of care for people with HIV infection. The results presented in this paper are the first nationally representative estimates of home care utilization by persons with HIV/AIDS and are discussed with reference to policy and future research.     

Social support networks and medical service use among HIV-positive injection drug users: implications to intervention

The study used network analysis to identify forms and sources of social support associated with a medical services use among a medically underserved population living with HIV/AIDS. Participants were African American former or current injection drug users (n=295; 34% female, 45% current drug users and 17% AIDS diagnosed). Outcomes were access to the same medical provider, use of outpatient services and emergency room (ER) use with or without subsequent hospitalization. Controlling for AIDS diagnosis, insurance, current drug use and gender, access to the same medical care provider was associated with more females in one's support network and more network sources of emotional support, financial support and instrumental assistance. Adjusting for confounders, outpatient service use was associated with more female support network members and more sources of emotional support. Controlling for participants' drug use and insurance, sub-optimal emergency department use was associated with greater number of active drug users in one's support network. Contrary to other study findings, having a supportive sex partner was associated with lower access to medical care, and kin support was not associated with medical service use. Results indicate that specific sources and forms of social support had differential influences on the sample's utilization of medical services. The findings suggest that promoting HIV-positive African American injection drug users' support network functioning may help improve HIV medical services utilization among this medically underserved population.     

Care available to severely disabled older persons living at home in Florence, Italy

AIMS: To characterize the epidemiology of disability in, and the level of care available to, older community-dwellers in an Italian urban sample. METHODS: In a 2-phase survey, persons aged 65+ years, randomly selected from the patients lists of 98 primary care physicians (PCP), were screened (phase I) by their PCP with a structured questionnaire to detect the presence of: 1) need of help in performing Basic and 2) Instrumental Activities of Daily Living (BADL, IADL); 3) poor vision or 4) hearing; 5) weight loss; 6) use of home care services; 7) self-perceived inadequacy of income. Subjects reporting 2+ problems were further evaluated in face-to-face structured interviews (phase II). RESULTS: Of 5,445 participants, 597 (11%) screened positive in phase I and 416 were interviewed in phase II. Of these, 4, 29, 19 and 49% were disabled in 1-2 IADL, 3+ IADL, 1-2 BADL, and 3+ BADL. The extent of the support network increased with disability severity (p<0.01). The 274 participants with BADL disability received most of their help from close relatives (58.3+/-2.5%), followed by salaried assistants (20.5+/-2.1%), other relatives (19.5+/-1.9%), and public healthcare services (0.6+/-0.36%). Of the 397 care-givers interviewed, one-third were willing to institutionalize the older participants in case of further functional deterioration. This propensity was predicted only by a self-reported poor attitude towards caring. CONCLUSION: Many severely disabled older Italians receive care in their home by highly supportive family members. The level of assistance provided to them by public healthcare services is minimal.     

Mortality in relation to instrumental activities of daily living: one-year follow-up in a Japanese urban community

One-year mortality among 7,573 elderly residents living in an urban Japanese community was observed in relation to disability in instrumental activities of daily living (IADL). Disability in IADL was assessed for seven items of activity, including using public transportation, using the telephone, and shopping. When the effects of age were controlled, the mortality rate was significantly higher in disabled than in nondisabled persons for all seven items for both males and females.     

Association between muscle mass and disability in performing instrumental activities of daily living (IADL) in community-dwelling elderly in Japan

This study describes the association between low muscle mass and disability in performing IADL in elderly, community-dwelling Japanese subjects. Subjects were 1268 elderly, community-dwelling Japanese aged 65 years or older. Low muscle mass was defined by appendicular muscle mass index (AMI, weight [kg]/height [m(2)]), measured by bioelectrical impedance analysis (BIA). We classified "middle" AMI as a value 1-2 standard deviation (SD) below the young normal mean of AMI and "low" as more than 2 SD below the young normal mean. Examination of IADL was performed using the Tokyo Metropolitan Institute of Gerontology Index of Competence (TMIG-IC) questionnaire. In this study, 17.2% and 26.2% of elderly men and women, respectively, were classified as having low muscle mass. There was a significant association with age and the change from normal to middle to low muscle mass in both men and women. The prevalence of IADL disability also increased significantly as muscle mass decreased. After adjustment for age and BMI, low muscle mass was significantly associated with IADL disability in men and women. Furthermore, middle muscle mass was significantly associated with IADL disability in women. This study revealed that low muscle mass, defined as a value 2 SD below the mean of young adults, had a significant association with IADL disability in elderly Japanese. Interventions to prevent age-related losses in muscle mass may be an effective strategy to prevent IADL disability among the elderly.     

安徽省两城市老年人生活自理能力及其相关因素的研究

目的：了解老年人生自理能力状况及其影响因素,方法：应用整群随机抽样方法,调查安徽省合肥,铜陵两城市老年日常生活活动能力,应用单因素和多因素logistic回归模型分析老年人生活自理能力受损的主要影响因素,结果：老年人日常生活动动（PADL）和日常家务活动功能（IADL）丧失率分别为7．2％和20．9％,女性功能丧失率高于男性,且随年龄的增长,功能丧失率逐渐升高,经多因素分析,活活自理能力功能丧失率与年龄,性别,教育程度,患病,经济和有无工作有关,结论：老年人生活自理能力随年龄增长而下降,女性知活自理能力低于男性,IADL功能丧失率高于PADL,老年人健康状况应引起重视。     

Disability and home care dynamics among older unmarried Americans

OBJECTIVES: We describe how paid and unpaid home care hours received by older unmarried Americans change in response to disability dynamics. We test whether responses to disability declines and improvements are symmetric; that is, we test whether reductions in care hours that are due to disability improvements are of similar magnitude to increases in care hours that are due to disability declines. METHODS: Using a national sample of older unmarried Americans, we examine changes in total hours, paid hours, and unpaid hours of care in response to declines and improvements in personal care (activities of daily living, or ADLs) and routine care (instrumental ADLs, or IADLs) disability. We model changes in the total hours of care received in the past month and jointly model changes in unpaid and paid hours, using Tobit models. RESULTS: Changes in the total hours of care received respond to both increases and decreases in the count of ADL limitations and appear close to symmetric. In contrast, responses to IADL disability dynamics appear to be far less symmetric: Although increases in the count of IADL limitations are met with substantial increases in the total hours of care, decreases are not met with correspondingly large declines in care. The same general pattern is found for unpaid and paid care, and for Medicaid-funded home care. DISCUSSION: Disability and care are not static constructs in old age. Older unmarried persons experience worsening, stabilizing, and recovery of function, and their care hours change accordingly. Evaluations of home care programs must be cognizant of such dynamic realities.     

Clinical Diagnosis and Disability Among Community Dwellers Aged 75 and Over: The Sydney Older Persons Study

Objectives : Disability is an important predictor of health and community service utilisation. Understanding its pathogenesis has implications for planning of future health services. The aim of our study was to examine the contribution of systemic, psychiatric and neurodegenerative diseases to disability in an “old‐old” population. Methods : 647 men and women over the age of 75 participated in the Sydney Older Person's Study. Disability in activities of daily living (ADL), instrumental activities of daily living (IADL) and mobility was assessed using self report, informant and clinician assessments. Diagnoses of systemic, psychiatric, neurodegenerative diseases were made by clinicians. Individual disease contribution to disability was assessed using multiple regression analysis. Contribution to disability by the groups of systemic, neurodegenerative and psychiatric diagnoses was assessed, using hierarchical regression. Results : Neurodegenerative diseases were the major contributors to ADL impairment. Systemic and psychiatric diseases played a role in IADL and mobility impairment, as did the neurodegenerative diseases. Of the neurodegenerative diseases, dementia/cognitive impairment and Parkinsonism/gait slowing particularly contributed to disability. Self‐report under‐identified the role of the neurodegenerative diseases in disability. It also introduced a gender effect, that the clinical measures did not share to the same extent. Conclusions : Neurodegenerative diseases are important contributors to disability and assessments and diagnosis of neurodegenerative diseases should be included in disability assessments. Self report under‐identifies the importance of these conditions.     

Functional limitations among home health care users in the National Health Interview Survey Supplement on Aging.

A case-control study compared home health care (HHC) users from the 1984 Supplement on Aging to users of other community services and of no community service, matched on age and gender. Examination of specific activities of daily living (ADLs), instrumental activities of daily living (IADLs), and sociodemographic variables showed that HHC users were significantly more limited than controls in every ADL and IADL. In multivariate analyses, HHC use was significantly associated with three ADLs (dressing, going outside, bathing), two IADLs (shopping, heavy housework), and poor health status.     

Day‐care service use is a risk factor for long‐term care placement in community‐dwelling dependent elderly

Aims: To identify predictors of long‐term care placement and to examine the effect of day‐care service use on long‐term care placement over a 36‐month follow‐up period among community‐dwelling dependent elderly. Methods: This study was a prospective cohort analysis of 1739 community‐dwelling elderly and 1442 caregivers registered in the Nagoya Longitudinal Study for Frail Elderly. Data included the clients' demographic characteristics, basic activities of daily living, comorbidities, and use of home care services, including the day‐care, visiting nurse, and home‐help services, as well as caregivers' demographic characteristics and care burden. Analysis of long‐term care placement over 36 month was conducted using Kaplan–Meier curves and multivariate Cox proportional hazards models. Results: Among the 1739 participants, 217 were institutionalized at long‐term care facilities during the 36‐month follow‐up. Multivariate Cox regression models, adjusted for potential confounders, showed that day‐care service use was significantly associated with an elevated risk for long‐term care placement within the 36‐month follow‐up period. Participants using a day‐care service two or more times/week had significantly higher relative hazard ratios than participants not using such a service. Conclusion: The results highlight the need for effective measures to reduce the long‐term care placement of day‐care service users. Policy makers and practitioners must consider implementing multidimensional support programs to reduce the caregivers' willingness to consider long‐term care placement. Geriatr Gerontol Int 2012; 12: 322–329.