Accumulation of deficits as a proxy measure of aging

This paper develops a method for appraising health status in elderly people. A frailty index was defined as the proportion of accumulated deficits (symptoms, signs, functional impairments, and laboratory abnormalities). It serves as an individual state variable, reflecting severity of illness and proximity to death. In a representative database of elderly Canadians we found that deficits accumulated at 3% per year, and show a gamma distribution, typical for systems with redundant components that can be used in case of failure of a given subsystem. Of note, the slope of the index is insensitive to the individual nature of the deficits, and serves as an important prognostic factor for life expectancy. The formula for estimating an individual's life span given the frailty index value is presented. For different patterns of cognitive impairments the average within-group index value increases with the severity of the cognitive impairment, and the relative variability of the index is significantly reduced. Finally, the statistical distribution of the frailty index sharply differs between well groups (gamma distribution) and morbid groups (normal distribution). This pattern reflects an increase in uncompensated deficits in impaired organisms, which would lead to illness of various etiologies, and ultimately to increased mortality. The accumulation of deficits is as an example of a macroscopic variable, i.e., one that reflects general properties of aging at the level of the whole organism rather than any given functional deficiency. In consequence, we propose that it may be used as a proxy measure of aging.

Physical activity and risk of cognitive impairment and dementia in elderly persons

CONTEXT

Dementia is common, costly, and highly age related. Little attention has been paid to the identification of modifiable lifestyle habits for its prevention.

OBJECTIVE

To explore the association between physical activity and the risk of cognitive impairment and dementia.

DESIGN, SETTING, AND SUBJECTS

Data come from a community sample of 9008 randomly selected men and women 65 years or older, who were evaluated in the 1991-1992 Canadian Study of Health and Aging, a prospective cohort study of dementia. Of the 6434 eligible subjects who were cognitively normal at baseline, 4615 completed a 5-year follow-up. Screening and clinical evaluations were done at both waves of the study. In 1996-1997, 3894 remained without cognitive impairment, 436 were diagnosed as having cognitive impairment-no dementia, and 285 were diagnosed as having dementia.

MAIN OUTCOME MEASURE

Incident cognitive impairment and dementia by levels of physical activity at baseline.

RESULTS

Compared with no exercise, physical activity was associated with lower risks of cognitive impairment, Alzheimer disease, and dementia of any type. Significant trends for increased protection with greater physical activity were observed. High levels of physical activity were associated with reduced risks of cognitive impairment (age-, sex-, and education-adjusted odds ratio, 0.58; 95% confidence interval, 0.41-0.83), Alzheimer disease (odds ratio, 0.50; 95% confidence interval, 0.28-0.90), and dementia of any type (odds ratio, 0.63; 95% confidence interval, 0.40-0.98).

CONCLUSION

Regular physical activity could represent an important and potent protective factor for cognitive decline and dementia in elderly persons.

Prevalence and severity of cognitive impairment with and without dementia in an elderly population

BACKGROUND

Not all cognitively impaired people have dementia, but those who do not meet current criteria for dementia have received little study. We report a comprehensive estimate of the prevalence of "cognitive impairment, no dementia" (CIND) in an elderly population.

METHODS

The Canadian Study of Health and Aging gathered population representation information about elderly Canadians aged 65 and over from 36 cities and surrounding areas in five regions. In each region, the sample size was 1800 people in the community and 250 people in institutions. Patients in the community were screened for cognitive impairment by means of the modified mini-mental state examination. Those who scored below the cut-off point (n = 1106) and a randomly selected sample of those who scored above the cut-off point (n = 494) were referred for clinical examination. 59 individuals unable to take the screening test were also assessed clinically. We selected 17 long-term care institutions in each region, and then randomly selected consenting residents of these institutions for clinical assessment (n = 1255).

RESULTS

The prevalence of CIND was 16.8%, which was more than all types of dementia combined (8.0%). The prevalence of all types of cognitive impairment, including dementias, increased with age. Patients with CIND were three times more likely to be living in institutions than were cognitively unimpaired patients (odds ratio 3-1 [95% CI 2.4-3.9]). Circumscribed memory loss has a prevalence of 5.3% in the elderly Canadian population, and was the most common category. CIND was related to some degree of functional impairment in elderly patients.

INTERPRETATION

CIND is commonly associated with functional disability and a need for institutional care. This diagnostic category includes a costly group of disorders that merit further study.

A reevaluation of the duration of survival after the onset of dementia

BACKGROUND

Dementia shortens life expectancy; estimates of median survival after the onset of dementia have ranged from 5 to 9.3 years. Previous studies of people with existing dementia, however, may have underestimated the deleterious effects of dementia on survival by failing to consider persons with rapidly progressive illness who died before they could be included in a study (referred to as length bias).

METHODS

We used data from the Canadian Study of Health and Aging to estimate survival from the onset of symptoms of dementia; the estimate was adjusted for length bias. A random sample of 10,263 subjects 65 years old or older from throughout Canada was screened for cognitive impairment. For those with dementia, we ascertained the date of onset and conducted follow-up for five years.

RESULTS

We analyzed data on 821 subjects, of whom 396 had probable Alzheimer's disease, 252 had possible Alzheimer's disease, and 173 had vascular dementia. For the group as a whole, the unadjusted median survival was 6.6 years (95 percent confidence interval, 6.2 to 7.1). After adjustment for length bias, the estimated median survival was 3.3 years (95 percent confidence interval, 2.7 to 4.0). The median survival was 3.1 years for subjects with probable Alzheimer's disease, 3.5 years for subjects with possible Alzheimer's disease, and 3.3 years for subjects with vascular dementia.

CONCLUSIONS

Median survival after the onset of dementia is much shorter than has previously been estimated.

The risk of dementia and death after delirium

BACKGROUND

delirium is common and is associated with many adverse short-term consequences.

OBJECTIVES

to examine the relationship between an episode of delirium and subsequent dementia and death over 3 years.

DESIGN

prospective cohort study.

SETTING

patients (n = 203) were aged 65 years or older at baseline and survivors of the index admission.

METHODS

Using a standard assessment of cognitive function, we followed 38 inpatients diagnosed with delirium (22 with delirium and dementia, 16 with delirium only) and 148 patients with no delirium or dementia, for a median of 32.5 months. Follow-up was by personal interviews, supplemented by standardized clinical examinations. We calculated the incidence and odds of dementia and the incidence and hazard ratio for death, with adjustment for potential confounders.

RESULTS

The incidence of dementia was 5.6% per year over 3 years for those without delirium and 18.1% per year for those with delirium. The unadjusted relative risk of dementia for those with delirium was 3.23 (95% confidence interval 1.86-5.63). The adjusted relative risk of death also increased (1.80; 1.11-2.92), while the median survival time was significantly shorter in those with (510 days; 433-587) than in those without delirium (1122 days; 922-1322).

CONCLUSION

delirium appears to be an important marker of risk for dementia and death, even in older people without prior cognitive or functional impairment.

Prevalence and outcomes of vascular cognitive impairment. Vascular Cognitive Impairment Investigators of the Canadian Study of Health and Aging

OBJECTIVE

To assess the importance of vascular cognitive impairment and its three subgroups (cognitive impairment, no dementia; vascular dementia; and AD with a vascular component) to the prevalence and burden of cognitive impairment in elderly people.

BACKGROUND

Vascular lesions may produce a spectrum of cognitive changes. Omitting elderly patients whose cognitive impairment falls short of dementia (vascular cognitive impairment, no dementia) may give a falsely low indication of the prevalence and burden of disease. To test this proposition, we compared the rates of adverse outcomes for patients with no cognitive impairment, vascular cognitive impairment (and its subgroups), and probable AD.

METHODS

The Canadian Study of Health and Aging is a prospective cohort study of 10,253 randomly selected community-dwelling and institution-dwelling respondents aged 65 years or older. In the community, all participants (n = 9,008) were screened for cognitive impairment; those who screened positive and a sample of those who screened negative received a clinical assessment (n = 1,659). All patients living in institutions received a clinical assessment (n = 1,255). Participants were reassessed 5 years after the original survey.

RESULTS

Vascular cognitive impairment without dementia was the most prevalent form of vascular cognitive impairment among those aged 65 to 84 years. Rates of institutionalization and mortality for those with vascular cognitive impairment were significantly higher than those of people who had no cognitive impairment, and the mortality rate for patients with vascular cognitive impairment was similar to that of patients with AD.

CONCLUSIONS

Failure to consider vascular cognitive impairment without dementia underestimates the prevalence of impairment and the risk for adverse outcomes associated with vascular cognitive impairment.

Conceptualisation and measurement of frailty in elderly people

The use of the term 'frailty' has shown tremendous growth in the last 15 years, but this has not been accompanied by a widely accepted definition, let alone agreed-upon measures. In this paper, we review approaches to the definition and measurement of frailty and discuss the relationship between frailty, aging and disability. Two trends are evident in definitions, which often trade off comprehensiveness for precision: frailty can be seen as being synonymous with a single-system problem or as a multisystem problem. The essential feature of frailty is the notion of risk due to instability (itself suggesting a balance of many factors), and has been only poorly measured to date. Future models of frailty should incorporate more precise operationalisation of the probability of frailty and better explain the relationship between disease, disability and frailty.

A Frailty Index Based On Deficit Accumulation Quantifies Mortality Risk in Humans and in Mice

Although many common diseases occur mostly in old age, the impact of ageing itself on disease risk and expression often goes unevaluated. To consider the impact of ageing requires some useful means of measuring variability in health in animals of the same age. In humans, this variability has been quantified by counting age-related health deficits in a frailty index. Here we show the results of extending that approach to mice. Across the life course, many important features of deficit accumulation are present in both species. These include gradual rates of deficit accumulation (slope = 0.029 in humans; 0.036 in mice), a submaximal limit (0.54 in humans; 0.44 in mice), and a strong relationship to mortality (1.05 [1.04–1.05] in humans; 1.15 [1.12–1.18] in mice). Quantifying deficit accumulation in individual mice provides a powerful new tool that can facilitate translation of research on ageing, including in relation to disease.

Research criteria for subcortical vascular dementia in clinical trials

Vascular dementia (VaD) incorporate different vascular mechanisms and changes in the brain, and have different causes and clinical manifestations. Variation in defining the cognitive syndrome, in vascular etiologies, and allowable brain changes in current clinical definitions of VaD have resulted in variable estimates of prevalence, of groups of subjects, and of the types and distribution of putative causal brain lesions. Thus current criteria for VaD select an etiologically and clinically heterogeneous group. This definitional heterogeneity may have been a factor in "negative" clinical trials. An alternative for clinical drug trials is to focus on a more homogeneous group, such as those with subcortical (ischemic) VaD. This designation incorporates two small vessel clinical entities "Binswanger's disease" and "the lacunar state". It comprises small vessel disease as the primary vascular etiology, lacunar infarct(s) and ischaemic white matter lesions as the primary type of brain lesions, and subcortical location as the primary location of lesions. The subcortical clinical syndrome is the primary clinical manifestation, a definition which still requires additional empirical data. We expect that subcortical VaD show a more predictable clinical picture, natural history, outcome, and treatment responses. We propose a modification of the NINDS-AIREN criteria as a new research criteria for subcortical VaD.

Vascular dementia : incidence and risk factors in the Canadian study of health and aging

BACKGROUND AND PURPOSE

Very few population-based studies have systematically examined incident vascular dementia (VaD). From the Canadian Study of Health and Aging cohort, incidence rates of VaD were determined and risk factors analyzed.

METHODS

This was a cohort incidence study that followed 8623 subjects presumed to be free of dementia over a 5-year period. The risk factors were examined with a nested prospective case-control study. Exposure was determined by means of a risk factor questionnaire administered to the subject or a proxy at the beginning of the study.

RESULTS

On the basis of 38 476 person-years at risk, the annual incidence rate was estimated to be 2.52 per thousand undemented Canadians (95% CI 2. 02 to 3.02). Including an estimation of the probability of VaD among the decedents, this figure rose to 3.79. For the risk factors study, 105 incident cases of VaD according to the NINCDS-AIREN criteria were compared with 802 control subjects. Significant risk factors were: age (OR=1.05), residing in a rural area (2.03), living in an institution (2.33), diabetes (2.15), depression (2.41), apolipoprotein E epsilon4 (2.34), hypertension for women (2.05), heart problems for men (2.52), taking aspirin (2.33), and occupational exposure to pesticides or fertilizers (2.05). Protective factors were eating shellfish (0.46) and regular exercise for women (0.46). There was no relation with sex, education, or alcohol.

CONCLUSIONS

The study confirmed some previously reported risk factors but also suggested new ones. It raised concerns about the prescription of aspirin and perhaps other factors related to rural life.

Acute confusion in elderly medical patients

The acute confusional state (delirium) is a common presentation for a wide variety of medical conditions in the elderly. This paper reports a prospective study of acute confusion in elderly people admitted to general medical services in two acute care hospitals in Edmonton, Alberta. Eighty patients were studied, ranging in age from 65-91. Acute confusion was seen in one-fourth of these patients, who tended to be older, more ill, more likely to have chronic cognitive impairment and a higher mortality rate. In patients admitted with confusion, infection and congestive heart failure predominated. In those who developed confusion after hospitalization, iatrogenic disease was more common. Confusion was a sensitive sign of physical illness, and its resolution accompanied recovery. A diagnosis of the cause of the confusion state could be made in 22 of 24 cases. These findings support the aggressive investigation and treatment of acute confusion in the elderly.

Effects of a flexible galantamine dose in Alzheimer's disease: a randomised, controlled trial

OBJECTIVE

To assess the efficacy and safety of galantamine in Alzheimer's disease at 3 months using flexible dose escalation.

METHODS

A randomised, double blind, placebo controlled trial in 43 centres in the United States, Canada, Great Britain, South Africa, Australia, and New Zealand. Patients with probable Alzheimer's disease (n=386; 171 women) with a score of 11-24 on the mini mental state examination, and a score> or =12 on the cognitive subscale of the Alzheimer's disease assessment scale (ADAS-cog) were randomised to placebo, or galantamine escalated over 4 weeks to a maintenance dose of 24 or 32 mg/day. The primary outcome measures were the change in ADAS-cog score and the clinician's interview based impression of change plus caregiver input (CIBIC-plus) score. Activities of daily living (ADL) and behavioural symptoms were secondary outcomes. To compare the effects of highest levels of dosing, an observed cases (OC) analysis was undertaken, with classic intention to treat (ITT) and ITT with last observation carried forward (LOCF) as confirmatory analyses.

RESULTS

At 3 months, galantamine (24-32 mg/day) produced a significantly better outcome on cognitive function than placebo (treatment difference=1.9 points on ADAS-cog, p=0.002) and a significantly better global response than placebo, as measured by CIBIC-plus (deterioration in 21% of patients on galantamine v 37% on placebo; p<0.001). Galantamine produced significant benefits on basic and instrumental ADL. Behavioural symptoms did not change significantly from baseline levels in either group. Adverse events (primarily gastrointestinal) were of mild to moderate intensity. There were no important differences between the OC, ITT, and ITT/LOCF analyses. Most patients (82%) who were maintained on the higher dose of galantamine completed the study.

CONCLUSIONS

Patients on galantamine, compared with those on placebo, experienced benefits in cognitive function and instrumental and basic activities of daily living. Flexible dose escalation of galantamine was well tolerated.

Feasibility and measurement properties of the functional reach and the timed up and go tests in the Canadian study of health and aging

BACKGROUND

Physical performance measures may offer advantages over self-report in the functional assessment of older people. Estimates of the feasibility, reliability, and construct validity of these measures in large, heterogeneous samples are necessary to establish their importance relative to traditional measures of function.

METHODS

Analysis of clinical data from Phase 2 of the Canadian Study of Health and Aging, a nation-wide representative survey of elderly people in Canada (N = 2,305).

RESULTS

Both physical performance measures proved infeasible in many subjects (29.3% for the Timed Up and Go [TUG], 35.9% for the Functional Reach [FR]). Cognitive impairment was the most important determinant of inability to complete the tests. For those able to complete the tests, cognitively unimpaired subjects could reach farther (median 29 cm) and complete the TUG in less time (median 12 seconds) than those cognitively impaired (25 cm for FR, 15 seconds for the TUG). Test-retest reliability between the screening and clinical administrations of the TUG was .56 for all participants (intra-class correlations), .50 for the cognitively unimpaired, and .56 for the cognitively impaired. Construct validity was substantial, and correlations between performance measures and self-report activities of daily living (ADL) measures ranged from .40 to .70. Compared with a global clinical measure of frailty, correlations were more modest (.38 to .60).

CONCLUSIONS

The FR and the TUG were not feasible tools in this study. The TUG showed poor test-retest reliability. Our data support the observation that subsequent studies of measurement instruments typically reveal lower performance than the original reports.

Progression of impairment in patients with vascular cognitive impairment without dementia

Little is known about progression, short of dementia, in vascular cognitive impairment. In the Canadian Study of Health and Aging, 149 participants (79.3 +/- 6.7 years; 61% women) were found to have vascular cognitive impairment, no dementia (CIND). After 5 years, 77 participants (52%) had died and 58 (46%) had developed dementia. Women were at greater risk of dementia (OR 2.1, 1.0 to 4.5). Of 32 participants alive without dementia, cognition had deteriorated in seven and improved in four. Half of those with vascular CIND developed dementia within 5 years, suggesting a target for preventive interventions.

Donepezil for treatment of dementia with Lewy bodies: a case series of nine patients

Dementia with Lewy bodies (DLB) is common. Symptomatic treatment can be difficult. We reviewed nine consecutive patients with DLB (mean age 77.5 [range 67 to 84] years; seven men and two women; mean duration of disease 3.7 [range 1.5 to 8.0] years) who had been treated with donepezil. Each initially received 2.5 to 5 mg per day of donepezil, and was stabilized on 5 mg per day. Donepezil was increased to 10 mg per day in five patients. The mean observation period was 12 (range 8 to 24) weeks. Target symptoms included cognition, hallucinations, parkinsonism, and functional abilities. By both cognitive testing and family reports, cognition improved in seven of nine patients, remained the same in one of nine, and fluctuated in one of nine (mean Mini-Mental State Examination change 4.4 +/- 6.3 points). Function was improved or maintained in six of nine patients and fluctuated in two of nine. Hallucinations initially worsened, then fluctuated in one patient, but improvement in frequency, duration, and content was reported in eight of nine cases. In three of nine patients, treatment with donepezil resulted in worsening of parkinsonism, which in each case responded to levodopa/carbidopa. Treatment of DLB patients with donepezil for 12 weeks most commonly improved hallucinations, and sometimes improved cognition and overall function. Treatment with donepezil was sometimes associated with worse parkinsonism.

Screening for PS1 mutations in a referral-based series of AD cases: 21 novel mutations

BACKGROUND

Mutations in the presenilin-1 gene (PS1) account for a majority of patients with early-onset familial AD. However, the clinical indications and algorithms for genetic testing in dementia are still evolving.

METHODS

The entire open reading frame of the PS1 gene was sequenced in a series of 414 consecutive patients referred for diagnostic testing, including 372 patients with AD and 42 asymptomatic persons with a strong family history of AD.

RESULTS

Forty-eight independent patients screened had a PS1 mutation including 21 novel mutations. In addition, 3% of subjects (11/413) had a known polymorphism, the Glu318Gly substitution. The majority of the mutations were missense substitutions but there were three insertions and Delta exon 10 mutation. With six exceptions (codons 35, 178, 352, 354, 358, and 365) most of the mutations occurred at residues conserved in the homologous PS2 gene or in PS1 of other species.

CONCLUSIONS

Eleven percent of a referral-based series of patients with AD can be explained by coding sequence mutations in the PS1 gene. The high frequency of PS1 mutations in this study indicates that screening for PS1 mutations in AD is likely to be successful, especially when directed at patients with a positive family history with onset before 60 years (90% of those with PS1 mutations were affected by age 60 years). This will also have significance for the secondary identification of at-risk relatives who might be candidates for future prophylactic therapies for AD.

Factors associated with institutionalization of older people in Canada: testing a multifactorial definition of frailty

OBJECTIVES

To test a model of frailty by examining factors associated with institutionalization of older people in Canada; to assess whether diagnostic data provided information about risk beyond that provided by data on functional capacity and demographic variables.

METHODS

Cross-sectional study of 1258 institutional subjects and 9113 community-dwelling older adults from the Canadian Study of Health and Aging.

RESULTS

Multiple logistic regression analysis showed that female gender, being unmarried, absence of a caregiver, presence of cognitive impairment (including all types of dementia), functional impairment, diabetes mellitus, stroke, and Parkinson's disease were independently associated with being in a long-term care facility.

CONCLUSION

Frailty appears to be a multidimensional construct, and not simply a synonym for dependence in Activities of Daily Living. Studies of health outcomes in older people should include diagnostic data as well as demographic information and data on functional capacity.

The occurrence and duration of symptoms in elderly patients with delirium

BACKGROUND

This study attempts to estimate the incidence, prevalence, and average duration of delirium in elderly patients; to assess the sensitivity of DSM-III and DSM-III-R in the diagnosis of delirium; and to compare the estimates of the duration of delirium using DSM-III and DSM-III-R criteria.

METHODS

A 12-month prospective descriptive study of 168 consecutively admitted patients and 5 additional patients with delirium was conducted in the Geriatric Assessment Unit of a teaching hospital. The duration in days of DSM-III and DSM-III-R symptoms for each delirious patient was assessed by two clinicians. The Barthel Index, Mini-Mental State Examination, and Trezpacz Delirium Symptom Rating Scale scores were also recorded.

RESULTS

The prevalence of delirium was 18% and the incidence was 7%. Compared to clinical judgment DSM-III-R showed 100% sensitivity. The mean duration of delirium was 8 +/- 9 days (DSM-III-R); the DSM estimate was 7 +/- 7 days. Complete symptom recovery was seen in only 52% of surviving patients. Prolonged memory impairment was common.

CONCLUSIONS

As operationalized in this study, DSM-III-R delirium criteria were more sensitive than DSM-III. Persistent symptoms are common in elderly patients with delirium.

Use of goal attainment scaling in measuring clinically important change in the frail elderly

The selection of appropriate outcome measures is important in evaluating specialized geriatric programs, but how the various measures compare, and which are most appropriate, are matters still largely unexplored. We compared several outcome measures, including goal attainment scaling, to assess their sensitivity to changes in the health status of frail elderly patients admitted to two geriatric medicine wards. GAS is a measurement approach which accommodates multiple individual patient goals, and has a scoring system which allows for comparisons between patients. Forty-five patients (mean age 81 years, 30 females) received comprehensive assessments. GAS yielded a mean 5 goals per patient. The mean gain in the GAS score was 22 points (SD = 7) which was compared with the change in the Barthel Index (r = 0.59), the Functional Independence Measure (r = 0.45), the Physical Self-Maintenance Scale (r = 0.54), the Katz Activities of Daily Living Index (r = 0.49) and the Spitzer Quality of Life Index (r = 0.38). The inter-rater reliability of scoring the GAS follow-up guides was 0.91. Using a relative efficiency statistic, GAS proved more efficient than any other measure. The effect size statistic also demonstrated an increased responsiveness to change of GAS compared with standard measures. GAS is an individualized measurement approach which shows promise as a responsive measure in frail elderly patients.

Increasing the recognition of delirium in elderly patients

OBJECTIVE

To determine if an educational intervention aimed at house staff will increase knowledge about and recognition of delirium.

DESIGN

Before/after study, with blinding of participants to the intent of the study.

SETTING

University hospital in Halifax, Nova Scotia.

PATIENTS

One hundred eighty-seven control patients, seen as consecutive admissions of elderly patients (65 + years) to the General Medicine services of the Victoria General Hospital prior to the educational intervention, and 247 patients seen thereafter.

INTERVENTION

Educational intervention at grand rounds, housestaff rounds, sign-in rounds, and bedside teaching.

MEASUREMENTS

Recognition of delirium in the admitting history or progress notes, Confusion Assessment Method (CAM) as recorded by nurses, diagnosis of delirium by independent study physicians using DSM-IIIR criteria and the Trzepacz Delirium Symptom Rating Scale.

RESULTS

Prior to the intervention, delirium or acute confusion was diagnosed in 3% of patients; after the intervention, delirium or acute confusion was diagnosed in 9% of patients (P < 0.01). Other abnormalities in mental state were noted in 8.5% of admissions prior to the intervention, and 15.6% of admissions after the intervention. After the intervention there was a significant difference in the proportion of patients in whom a mental status questionnaire had been carried out and in whom there was formal comment on various aspects of the mental state. The nursing CAM had a sensitivity of 0.68 and a specificity of 0.97.

CONCLUSIONS

A simple educational intervention aimed at house staff appears to be effective in changing house staff behavior. Improved recognition of delirium may lead to better patient outcomes.

Use of goal attainment scaling in measuring clinically important change in cognitive rehabilitation patients

Measuring the effectiveness of cognitive rehabilitation programs poses both conceptual and practical challenges. We compared several standardized outcome measures with goal attainment scaling (GAS) to assess their sensitivity to changes in health status in patients undergoing cognitive rehabilitation. GAS is a measurement approach that accommodates multiple individual patient goals, and has a scoring system which allows for comparisons between patients. Forty-four patients were evaluated. GAS yielded a mean 4.4 goals per patient. The mean gain in the GAS score was compared with the change in the Rappaport Disability Rating Scale, the Kohlman Evaluation of Daily Living Skills, the Milwaukee Evaluation of Daily Living, the Klein-Bell elimination scale and mobility scale, the Instrumental Activities of Daily Living Scale, and the Spitzer Quality of Life Index. Using a relative efficiency statistic, GAS proved more responsive than any other measure. The effect size statistic also demonstrated greater responsiveness to change with GAS compared with standard measures. GAS shows promise as a responsive measure in cognitive rehabilitation. This study replicates a similar study of GAS in frail elderly patients, suggesting that individualized measures may have broad merit in evaluating rehabilitation programs.

Multidimensionality in instrumental and basic activities of daily living

Although the use of self-reported ADL (activity of daily living) scales has a long history, the Katz-based assumptions of unidimensionality and hierarchy are increasingly found lacking, and ADLs alone are found to underestimate dysfunction and disability. Data from nearly 8900 elderly respondents in the community sample of the 1991 Canadian Study of Health and Aging were used to examine the measurement properties of a modified version of the Older Americans Research Survey (OARS) ADL and IADL items combined. A multidimensional factor structure was revealed, with three levels of functional ability possessing internal consistency. We conclude that assumptions regarding ADL/IADL unidimensionality and hierarchy are not always valid, and that ADL and IADL items should be considered in combination to capture a greater range of functional disability prevalence. We also suggest that expectations of precise measurement of functional dependence by (I)ADL scales should perhaps be relaxed to the goal of simply differentiating broad levels of self-reported functioning (such as basic, intermediate, and complex), within which some tasks are roughly equivalent. Because these scales are widely used as screening tools and in shaping policy, we suggest that employing a more empirically grounded measurement standard has the potential to reduce bias due to item complexity and task specificity, facilitate standardization, and more reliably predict outcomes.

Prevalence of and factors associated with frailty and disability in older adults from China, Ghana, India, Mexico, Russia and South Africa

BACKGROUND

The severe burden imposed by frailty and disability in old age is a major challenge for healthcare systems in low- and middle-income countries alike. The current study aimed to provide estimates of the prevalence of frailty and disability in older adult populations and to examine their relationship with socioeconomic factors in six countries.

METHODS

Focusing on adults aged 50+ years, a frailty index was constructed as the proportion of deficits in 40 variables, and disability was assessed using the World Health Organization Disability Assessment Schedule (WHODAS 2.0), as part of the Study on global AGEing and adult health (SAGE) Wave 1 in China, Ghana, India, Mexico, Russia and South Africa.

RESULTS

This study included a total of 34,123 respondents. China had the lowest percentages of older adults with frailty (13.1%) and with disability (69.6%), whereas India had the highest percentages (55.5% and 93.3%, respectively). Both frailty and disability increased with age for all countries, and were more frequent in women, although the sex gap varied across countries. Lower levels of both frailty and disability were observed at higher levels of education and wealth. Both education and income were protective factors for frailty and disability in China, India and Russia, whereas only income was protective in Mexico, and only education in South Africa.

CONCLUSIONS

Age-related frailty and disability are increasing concerns for older adult populations in low- and middle-income countries. The results indicate that lower levels of frailty and disability can be achieved for older people, and the study highlights the need for targeted preventive approaches and support programs.

One-year outcome of elderly and young patients admitted to intensive care units

OBJECTIVE

To compare the outcome of patients over and under age 65 admitted to two intensive care units (ICUs).

DESIGN

Prospective, two-center study. Convenience sample of all admissions to two adult ICUs for a 1-yr period, with a 1-yr follow-up.

SETTING

Adult multidisciplinary closed ICUs.

PATIENTS

All patients (n = 1,040) admitted to two ICUs during a 1-yr period were entered into the study, except patients with self-induced poisoning. Of these patients, 145 patients were lost to follow-up.

INTERVENTIONS

Admission statistics on all patients included demographic, case mix, and severity data. Variables associated with intensive care unit outcomes at discharge (length of stay, mortality) and at 1 yr from admission (mortality, functional capacity, health attitudes) were analyzed. Vital status was confirmed from both Alberta Vital Statistics and Alberta Health. Follow-up interviews were conducted with all available survivors.

RESULTS

The elderly group (> 65 yrs) comprised 46% of patients studied. Both age groups (> 65 yrs and < 65 yrs) had comparable demographics and illness severity measures. Although ICU and 1-yr mortality rates differed between groups (16% of > 65 yrs vs. 12.9% of < 65 yrs ICU mortality and 49% of > 65 yrs vs. 31% of < 65 yrs 1-yr mortality), age was not a major contributor to the variance in outcome. At 1 yr, 65% of patients admitted to the study were alive. Follow-up interviews were conducted with 75% of survivors. Assessment of activities of daily living showed that the elderly patients were similar to younger patients. The elderly demonstrated more positive health attitudes than younger survivors. Functional capacity was significantly associated with health attitudes of younger patients, but not for older survivors.

CONCLUSIONS

Age does not have an important impact on outcome from critical illness, which is most strongly predicted by severity of illness, length of stay, prior ICU admission and respiratory failure. Satisfaction with personal health should not be inferred from the functional status of elderly survivors of intensive care.