The effects of specific medical conditions on the functional limitations of elders in the Framingham Study

Incidence of functional limitation in older adults: the impact of gender, race, and chronic conditions

OBJECTIVES

To evaluate the relation of chronic conditions, gender, and race to the incidence of activities of daily living (ADLs) limitation in older adults.

DESIGN

The 2-year cumulative incidence of functional limitation was estimated from survival analysis methods by using elders without baseline functional limitations.

SETTING

Longitudinal Study of Aging (LSOA). Initial interviews: 1984; reinterviews: 1986, 1988, and 1990.

PARTICIPANTS

A total of 4205 elderly subjects from the LSOA.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

DEPENDENT VARIABLES

self-reported moderate (1-2 ADLs) and severe (> or =3 ADLs) functional limitation.

INDEPENDENT VARIABLES

sociodemographics, self-reported chronic conditions, and prior levels of functional limitation.

RESULTS

Gender and race predicted moderate functional limitation onset, after controlling for age and education. Arthritis, diabetes, prior cerebrovascular disease (CVD), incontinence, and impaired vision were significant predictors of moderate functional limitation onset after controlling for demographics. Differences in the prevalence of chronic conditions appear to explain why moderate functional limitation incidence rates are higher in older women and blacks. Gender, but not race, predicted onset of severe functional limitation, after controlling for age and education. Prior moderate functional limitation, CVD, and vision impairment predicted onset of severe functional limitation after controlling for demographics.

CONCLUSION

Prevention of functional decline should target chronic conditions and moderate functional limitation in older adults.

Bedingungen der Erhaltung und Förderung von Selbstständigkeit im höheren Lebensalter (SIMA)

Zusammenfassung: Im Rahmen der 1991 begonnenen Längsschnittstudie SIMA wurde die Entwicklung der Selbstständigkeit der Teilnehmer zwischen 1991 und 1998 verfolgt. Für insgesamt 340 der ursprünglich 375 Teilnehmer ließ sich bis Ende 1998 der Status im Hinblick auf Unselbstständigkeit, Demenz und Mortalität ermitteln. Die Teilnehmer lebten bei Studienbeginn selbstständig und waren zwischen 75 und 93 Jahren bzw. im Mittel 79,5 ± 3,5 Jahre alt. In multivariaten Risikoanalysen (Cox Regression) wurden signifikante medizinische und psychologische Risikofaktoren bestätigt. Als hoch signifikante Unselbstständigkeitsrisiken erwiesen sich Apoplex, Depression, eine submediane subjektive Bewertung der Befindlichkeit sowie spezifische Gedächtnisdefizite. Als bedeutendste Demenzrisiken ließen sich verschiedene kognitive Leistungsdefizite und das Vorliegen einer Frühsymptomatik identifizieren. Die höchsten Zusammenhänge mit der Mortalität wiesen Rauchen, Diabetes mellitus sowie jeweils eine subjektive Bewertung der Gesundheit und eine körperliche Leistungsfähigkeit unter dem Gruppenmedian auf. Die Befunde der SIMA-Studie zeigen, dass weder eine hohe Multimorbidität noch einzelne typische Erkrankungen die ausschließlichen Unselbstständigkeits-, Demenz- oder Mortalitätsrisiken im höheren Lebensalter darstellen. Die gleichzeitige Bedeutung psychologischer Risikofaktoren, z. B. von Einschränkungen in der Befindlichkeit oder Defiziten in visuellen Gedächtnisleistungen bzw. der kognitiven Geschwindigkeit, sowie eines Mangels an körperlichen Aktivitäten dokumentiert zudem, dass einer Unselbstständigkeit und möglicherweise auch einer Demenz durch ein multimodales Trainingsprogramm erfolgreich begegnet werden kann.

Testing the effect of the WALC intervention on exercise adherence in older adults

The purpose of this study was to test the feasibility of the WALC intervention (Walk; Address pain, fear, fatigue during exercise; Learn about exercise; Cue by self-modeling), and determine its effects on self-efficacy and outcome expectations, exercise activity and free living activity, physical and mental health status, and falls and fall-related injuries. A total of 17 sedentary older women with a mean age of 88 +/- 3.7 years were randomly assigned to receive either the WALC intervention or routine care. Ninety percent of those in the treatment group initiated and engaged in a regular exercise program during the 6 months of the study. There was a statistically significant difference in self-efficacy expectations, exercise behavior, and overall activity between the two groups. Those in the treatment group had stronger self-efficacy expectations related to exercise; engaged in more exercise and more free living activity; and although not statistically significant, had stronger outcome expectations following exposure to the WALC intervention when compared with those who received routine care. To help older adults initiate and adhere to an exercise program, nurses can easily implement the WALC intervention in a variety of settings.

Comorbidities and impairments explaining the association between diabetes and lower extremity disability: The Women's Health and Aging Study

OBJECTIVE

To elucidate the role of diabetes-related impairments and comorbidities in the association between diabetes and physical disability, this study examined the association between diabetes and lower extremity function in a sample of disabled older women.

RESEARCH DESIGN AND METHODS

Cross-sectional analysis of 1,002 women (aged >or=65 years) enrolled in the Women's Health and Aging Study (one-third most disabled of the total community-dwelling population). Diabetes and other medical conditions were ascertained by standard criteria that used multiple sources of information. Functional status was assessed using self-reported and objective performance measures.

RESULTS

Women with diabetes were significantly more likely to have cardiovascular diseases, peripheral nerve dysfunction, visual impairment, obesity, and depression. After adjustment for age, women with diabetes had a greater prevalence of mobility disability (odds ratio [OR] 1.85, 95% CI 1.12-3.06), activities of daily living disability (1.61, 1.06-2.43), and severe walking limitation (2.34, 1.56-3.50), and their summary mobility performance score (0-12 scale based on balance, gait speed, chair stands) was 1.4 points lower than in nondiabetic women (P < 0.001). Peripheral artery disease, peripheral nerve dysfunction, and depression were the main individual contributing factors; however, none of these conditions alone fully explained the association between diabetes and disability. Conversely, only after adjusting for all potential mediators was the relationship between diabetes and disability reduced to a large degree.

CONCLUSIONS

Even among physically impaired older women, diabetes is associated with a major burden of disability. A wide range of impairments and comorbidities explains the diabetes-disability relationship, suggesting that the mechanism for such an association is multifactorial.

Surface size, curvature analysis, and assessment of knee joint incongruity with MRI in vivo

The purpose of this study was to develop an MR-based technique for quantitative analysis of joint surface size, surface curvature, and joint incongruity and to assess its reproducibility under in vivo imaging conditions. The surface areas were determined after 3D reconstruction of the joint by triangulation and the incongruity by Gaussian curvature analysis. The precision was tested by analyzing four replicated MRI datasets of human knees in 14 individuals. The algorithms were shown to produce accurate data in geometric test objects. The interscan precision was <4% (CV%) for surface area, 2.9-5.7 m(-1) (SD) for the mean principal curvature, and 4.1-7.4 m(-1) for congruence indices. Incongruity was highest in the femoropatellar joint (79.7 m(-1)) and lowest in the medial femorotibial joint (28.6 m(-1)). This technique will permit identification of the specific role of surface size, curvature, and incongruity as potential risk factors for osteoarthritis.

Health status of participants of adult day care centers

This study compared the medical conditions found in 183 participants of 5 suburban adult day care programs to the medical and mental health status of community-dwelling elderly persons. Analysis revealed that adult day care center participants are very similar to the community-dwelling elderly population in most health indicators, but suffer from much higher rates of dementia and associated functional disabilities. Moreover, those day care participants who do not suffer from dementia tend to suffer from a psychiatric disorder (e.g., major depression, adjustment disorder). These results show that adult day care has become a facility with a primary mental health function.

Peripheral artery disease, diabetes, and reduced lower extremity functioning

OBJECTIVE

To characterize lower extremity function and dysfunction in peripheral artery disease (PAD) patients with and without diabetes.

RESEARCH DESIGN AND METHODS

In this cross-sectional study, 460 men and women with PAD (147 with diabetes) were recruited from three academic medical centers. Assessments included ankle brachial index (ABI), neuropathy score, 6-min walk distance, 4-m walking velocity, Walking Impairment Questionnaire (0-100 scale, 100 = best), and summary performance score (SPS) (0-12 scale, 12 = best).

RESULTS

The mean ABI was similar in PAD patients with and without diabetes. PAD patients with diabetes were younger, had a higher BMI, had a worse neuropathy score, and had a greater number of cardiovascular comorbidities compared with those without diabetes. Participants with diabetes were less likely to report classical symptoms of intermittent claudication and more likely to report exertional leg pain, which sometimes started at rest. After adjusting for age, those with diabetes had a shorter mean 6-min walk distance (1,040 vs. 1,168 feet, P < 0.001), slower fast-pace 4-m walk velocity (0.83 vs. 0.90 m/sec, P < 0.001), and a lower SPS (7.3 vs. 8.6, P < 0.001) than those without diabetes. Patients with diet-controlled diabetes performed better than those on diabetes medications. Differences in lower extremity functioning between patients with and without diabetes were largely attenuated but not abolished for SPS and fast-pace 4-m walk velocity after adjustment for type of exertional leg pain, neuropathy score, and number of cardiovascular comorbidities.

CONCLUSIONS

Subjects with PAD and diabetes have poorer lower extremity function than those with PAD alone. This difference in functioning appears to be largely explained by diabetes-associated neuropathy, differences in exertional leg symptoms, and greater cardiovascular disease in patients with diabetes.

The APOE-E4 allele and the risk of functional decline in a community sample of African American and white older adults

BACKGROUND

Given previous findings of adverse health outcomes associated with the E4 allele, data from a biracial community sample of older adults were used to determine whether functional decline is associated with the apolipoprotein E (APOE) E4 allele.

METHODS

In 1986, a stratified random household sample of community residents 65 years of age and older (n = 4162) formed the Duke Established Populations for Epidemiologic Studies of the Elderly. Of those available 6 years later, 78.4% (n = 1999) were genotyped, providing "baseline" data at this time. The available survivors (n = 1529) provided longitudinal data 4 years later. Using longitudinal data from this sample, a combination of measures assessing self-care capability, instrumental activities of daily living (IADL), and mobility was obtained at baseline and 4 years later (n = 1529) to determine the extent to which the E4 allele affected change in functional status. Functional status was assessed using items from a modified Katz Activities of Daily Living (ADL) Scale, the Older American Resources and Services IADL scale, and the Rosow-Breslau physical health scale. Control measures included demographic characteristics, depression, health status, arthritis, and cognitive status. APOE was coded as E4 present versus absent.

RESULTS

APOE E4 was not associated with decline in functional status in either bivariate or multivariate analyses as a main effect. There were, however, statistically significant interactions of the E4 allele with gender and baseline functional status, with greater functional decline in women with the E4 allele, whereas those with poorer baseline functioning who had the E4 allele were less likely to decline. No significant racial differences were found.

CONCLUSIONS

Despite the documented association of the E4 allele of APOE with adverse health outcomes, the E4 allele was not associated with a decline in functional status as a main effect. Interactions of E4 with gender (being female) and baseline functional status, however, did predict functional decline.

Medical comorbidity and rehabilitation efficiency in geriatric inpatients

OBJECTIVES

To measure and describe medical comorbidity in geriatric rehabilitation patients and investigate its relationship to rehabilitation efficiency.

DESIGN

Prospective, multivariate, within-subject design.

SETTING

The Geriatric Rehabilitation inpatient unit of the SCO Health Service in Ottawa, Canada.

PARTICIPANTS

One hundred ten patients, with a mean age of 82 years.

MEASUREMENTS

The rehabilitation efficiency ratio, based on gains in functional status achieved with rehabilitation treatment, and the length of stay were computed for all patients. Values were regressed on the scores of the Cumulative Illness Rating Scale (CIRS), the Mini-Mental State Examination, and the Geriatric Depression Scale to establish predictive power.

RESULTS

The findings suggest that geriatric rehabilitation patients experience considerable medical comorbidity. Sixty percent of patients had impairments across six of the 13 dimensions of the CIRS, whereas 36% of patients had impairments across 11 of the 13 dimensions. In addition, medical comorbidity was negatively related to rehabilitation efficiency. This relationship was significant even after controlling for age, cognitive status, depressive symptoms, and functional independence status at admission.

CONCLUSION

Medical comorbidity was a significant predictor of rehabilitation efficiency in geriatric patients. Comorbidity scores >5 were prognostic of poorer rehabilitation outcomes and can serve as an empirical guide in estimating a patient's suitability for rehabilitation. Medical comorbidity predicted both the overall functional change achieved with retabilitation (Functional Independence Measure gains) and the rate at with which those gains were reached (rehabilitation efficiency ratio).

The physical functioning inventory: a procedure for assessing physical function in adults

The Physical Functioning Inventory, an instrument designed to assess changes in how and how often activities are performed in persons reporting difficulty with a task as well as in those who do not, is described. The measure is designed for adults. Interrater and test-retest reliability were assessed with active participants in the Baltimore Longitudinal Study of Aging (BLSA). Percentage agreement ranged from 63% to 100%. The instrument was also given to 392 inactive BLSA participants as part of a follow-up telephone interview. Fifty-eight percent of the respondents reported no difficulty in performing a task, yet reported a change in how often they performed that task. The results indicate that the instrument is reliable and effective in detecting early stages of disability in activities of daily living, instrumental activities of daily living, and mobility. The instrument is somewhat less reliable for moderate and strenuous physical activities.

Modifiers of change in physical functioning in older adults with knee pain: the Observational Arthritis Study in Seniors (OASIS)

OBJECTIVE

To ascertain predictors of decline in physical functioning among older adults reporting knee pain.

METHODS

The Observational Arthritis Study in Seniors was a longitudinal study of 480 adults over 65 years of age. Measurements of strength, sociodemographic characteristics, disease burden (including radiographic knee osteoarthritis [OA]), self-reported disability, and functional limitations were obtained on participants at baseline and at 15 and 30 months.

RESULTS

Radiographic evidence of OA at baseline was moderately associated with an increased decline in both transfer (P = 0.06) and ambulatory-based performance tasks (P = 0.04) but not in self-reported disability. This effect disappeared after accounting for baseline levels of knee pain intensity and knee strength.

CONCLUSION

Knee pain intensity and knee strength may mediate the relationship between radiographic evidence of knee OA and change in performance. Although it is not clear whether joint disease precedes or follows a decline in muscular strength, these results may help to identify subpopulations of older persons with knee OA who may benefit from interventions aimed at slowing the progression of disability related to transfer and ambulatory-based tasks.

Prevalence of morbidity and multimorbidity in elderly male populations and their impact on 10-year all-cause mortality: The FINE study (Finland, Italy, Netherlands, Elderly)

Older males are known to carry, more likely than younger people, one or more chronic diseases with an expected impact on mortality. This study was aimed at identifying the relationship of prevalent chronic diseases in elderly populations of different countries with all-cause mortality. Men aged 65-84 from defined areas were enrolled in Finland (N=716), the Netherlands (N=887) and Italy (N=682). They were survivors of cohorts studied for 25 years within the Seven Countries Study. Major chronic diseases were diagnosed at entry. Ten-year follow-up for mortality was completed. Entry prevalence of selected chronic diseases was higher in Finland (56%) than in Italy (51%) and the Netherlands (44%). Ten-year age-adjusted death rates from all causes were higher in Finland (565 per 1000) and lower in the Netherlands (478 per 1000) and Italy (445 per 1000). The absolute risk of death related to chronic disease was high in the three countries, but was higher in Finland than in the Netherlands and Italy. The most lethal condition was stroke, with 10-year death rates of 806 per 1000 in Finland and 707 and 729 per 1000 in the Netherlands and Italy, respectively. The relative risk of all-cause mortality for a set of seven chronic diseases (coronary heart disease, heart failure, claudicatio intermittens, cerebrovascular accidents, diabetes, COPD and cancer) adjusted by age, other diseases and cohort was less than two for each condition, except cerebrovascular accidents in the Netherlands (RR 2.20). In general, relative risk was higher in Finland, intermediate in the Netherlands and lower in Italy, where only cerebrovascular accidents, intermittent claudication, diabetes and the presence of any chronic condition had a significant relative risk. About one third of men had one chronic disease, and between 10% and 15% had two diseases. The coexistence of any two or three chronic conditions was associated with a relative risk of 2 or more in Finland and the Netherlands and less than 2 in Italy. In these elderly men prevalent morbidity and comorbidity was relatively common and it explained a large proportion of excess in all-cause mortality in 10 years of follow-up.

Risk adjustment for measuring health outcomes: an application in VA long-term care

An empirically derived risk adjustment model is useful in distinguishing among facilities in their quality of care. We used Veterans Affairs (VA) administrative databases to develop and validate a risk adjustment model to predict decline in functional status, an important outcome measure in long-term care, among patients residing in VA long-term care facilities. This model was used to compare facilities on adjusted and unadjusted rates of decline. Predictors of decline included age, time between assessments, baseline functional status, terminal illness, pressure ulcers, pulmonary disease, cancer, arthritis, congestive heart failure, substance-related disorders, and various neurologic disorders. The model performed well in the development and validation databases (c statistics, 0.70 and 0.68, respectively). Risk-adjusted rates and rankings of facilities differed from unadjusted ratings. We conclude that judgments of facility performance depend on whether risk-adjusted or unadjusted decline rates are used. Valid risk adjustment models are therefore necessary when comparing facilities on outcomes.

Profile of arthritis disability

Using the 1994-95 National Health Interview Supplement Disability Supplement, the authors study levels of disabilities and accommodations among US adults with arthritis disability, compared to people with disability due to other conditions. Arthritis-disabled people are defined in two ways. One definition covers a broad range of arthritis and rheumatic conditions, and the other concentrates solely on arthritis. The authors find that arthritis-disabled people have more total disabilities than other-disabled peop e. However, their disabilities are less severe, have shorter durations, and accumulate more gradually over time. Despite more disabilities, people with arthritis disability use fewer assistive and service accommodations than other-disabled people. They do use more mobility aids. Because arthritis is the leading chronic condition for middle-aged and older adults, th s profile of extensive but mild-to-moderate disability is experienced by many millions of adults. Accommodations for arthritis may also be extensive but aimed more toward self-care than toward assistive and medical services.

Problems in the development and validation of questionnaire-based screening instruments for ascertaining cases with symptomatic knee osteoarthritis: The Framingham Study

OBJECTIVE

To determine if screening for symptomatic knee osteoarthritis (OA) for clinical trials and epidemiologic studies could be satisfactorily done without performing knee radiographs and to develop efficient screening instruments for symptomatic knee OA based on self-reported symptoms and functional limitations.

METHODS

We administered a mailed questionnaire containing many different questions on knee symptoms and functional limitations to 1,921 participants of the Framingham Study who had previously been screened for symptomatic OA with a history and knee radiographs. Recursive partitioning methods (using the Classification and Regression Trees [CART] program) were used to create a set of screening instruments for symptomatic knee OA, which was defined as knee symptoms on most days and radiographic evidence of OA. Three screening instruments were developed to maximize the sensitivity, specificity, and efficiency.

RESULTS

The sensitive instrument had 84% sensitivity and 73% specificity. The specific instrument had 46% sensitivity and 94% specificity. The efficient instrument had 56% sensitivity and 85% specificity. Sensitivity was lower and specificity was higher when these instruments were used to screen for radiographic OA. All instruments had higher sensitivity but lower specificity when used for older subjects (age >60) with greater disease prevalence. However, using any of these instruments as a single-step screening mechanism resulted in considerable misclassification.

CONCLUSION

We conclude that none of these instruments has adequate diagnostic test performance to serve as a single-step evaluation of the presence or absence of symptomatic knee OA.

Exercise for knee osteoarthritis

Adverse outcomes in knee osteoarthritis include pain, loss of function, and disability. These outcomes can have devastating effects on the quality of life of those suffering from the disease. Treatments have generally targeted pain, assuming that disability would improve as a direct result of improvements in pain. However, there is evidence to suggest that determinants of pain and disability differ. In general, treatments have been more successful at decreasing pain rather than disability. Many of the factors that lead to disability can be improved with exercise. Exercise, both aerobic and strength training, have been examined as treatments for knee osteoarthritis, with considerable variability in the results. The variability between studies may be due to differences in study design, exercise protocols, and participants in the studies. Although there is variability among studies, it is notable that a majority of the studies had a positive effect on pain and or disability. The mechanism of exercise remains unclear and merits future studies to better define a concise, clear exercise protocol that may have the potential for a public health intervention.

The association between varus-valgus alignment and patellofemoral osteoarthritis

OBJECTIVE

Little is known about risk factors for patellofemoral (PF) osteoarthritis (OA). The lateral vector at the PF joint increases the likelihood of lateral PF versus medial PF pathology. Both valgus and varus malalignments affect forces at the PF joint and may predispose to PF OA. We examined whether lateral PF OA is more common than medial PF OA, whether valgus malalignment is more frequent in lateral PF OA than in medial PF OA, and whether knees with PF OA are more often valgus than knees with isolated tibiofemoral (TF) OA.

METHODS

In 292 knee OA patients, we obtained semiflexed, fluoroscopy-confirmed radiographs of the TF joint and weight-bearing, 30 degrees flexion, axial views of the PF joint. Varus-valgus alignment (the angle formed by the intersection of the mechanical axes of the femur and tibia) was measured on a full-limb radiograph.

RESULTS

Lateral PF OA was more common than medial PF OA (P<0.0001). Forty-three of 75 knees with lateral PF OA had valgus malalignment compared with only 5 of 21 patients with medial PF OA (P = 0.0066). Conversely, varus malalignment was more likely in the medial PF OA group. Knees with isolated PF OA were more likely to have valgus malalignment than those with isolated TF OA (P = 0.0002), as were knees with mixed PF-TF OA (P = 0.0006).

CONCLUSION

Varus-valgus alignment may influence the risk of PF OA and, in particular, which compartment is affected.

Smoking and the compression of morbidity

OBJECTIVE

To examine whether eliminating smoking will lead to a reduction in the number of years lived with disability (that is, absolute compression of morbidity).

DESIGN

Multistate life table calculations based on the longitudinal GLOBE study (the Netherlands) combined with the Longitudinal Study of Aging (LSOA, United States of America).

SETTING

the Netherlands.

SUBJECTS

Dutch nationals aged 30-74 years living in the city of Eindhoven and surrounding municipalities (GLOBE) and United States citizens age 70 and over (LSOA).

MAIN OUTCOME MEASURES

Life expectancy with and without disability and total life expectancy at ages 30 and 70.

RESULTS

A non-smoking population on balance spends fewer years with disability than a mixed smoking-non-smoking population. Although non-smokers have lower mortality risks and thus are exposed to disability over a longer period of time, their lower incidence of disability and higher recovery from disability yield a net reduction of the length of time spent with disability (at age 30: -0.9 years in men and -1.1 years in women) and increases the length of time lived without disability (2.5 and 1.9 years, for men and women, respectively). These outcomes indicate that elimination of smoking will extend life and the period of disability free life, and will compress disability into a shorter period.

CONCLUSIONS

Eliminating smoking will not only extend life and result in an increase in the number of years lived without disability, but will also compress disability into a shorter period. This implies that the commonly found trade off between longer life and a longer period with disability does not apply. Interventions to discourage smoking should receive high priority.

Glucosamine HCl reduces equine articular cartilage degradation in explant culture

Objective To determine whether glucosamine inhibits experimentally induced degradation of equine articular cartilage explants. Methods Articular cartilage was obtained from the antebrachio-carpal and middle joints of horses (2-8 years old) killed for reasons unrelated to lameness. Cartilage discs were harvested from the weight-bearing region of the articular surface and cultured. Media were exchanged daily and the recovered media stored at 4 degrees C. Explants were maintained in basal media 2 days prior to the start of four treatment days. On days 1-4 lipopolysaccharide (LPS, 10 microg/ml) or recombinant human interleukin-1 (rhIL-1, 50 ng/ml) were added to induce cartilage degradation. To test the potential protective effects of glucosamine, the compound was added in three concentrations (0.25, 2.5, or 25 mg/ml) and treatments were performed in triplicate. Controls included wells without LPS, rhIL-1beta, or glucosamine. Nitric oxide, proteoglycan and matrix metalloproteinases (MMP) released into conditioned media and tissue proteoglycan synthesis were measured as indicators of cartilage metabolism. Results Maximal nitric oxide production, proteoglycan release, and MMP activity were detected 1 day after the addition of LPS or rhIL-1beta to the media. The addition of 25 mg/ml of glucosamine prevented the increase in nitric oxide production, proteoglycan release and MMP activity induced by LPS or rhIL-1. Conclusions These data indicate that glucosamine can prevent experimentally induced cartilage degradation in vitro.

Protein nutritional status and function are associated with type 2 diabetes in Hispanic elders

BACKGROUND

Hispanic elders have a high prevalence of diabetes and poor glycemic control, leading to inadequate nutritional status, muscle wasting, and impaired function.

OBJECTIVE

We examined the association of type 2 diabetes with nutritional status measured by serum albumin concentrations and midupper arm muscle area (MAM) and with function measured by difficulty with at least one activity of daily living.

DESIGN

: Health history and disability were assessed by self report in 556 Hispanics with a mean (+/- SD) age of 69 +/- 7 y and 158 non-Hispanic whites (NHW; aged 71 +/- 7 y) from the Massachusetts Hispanic Elders Survey. Energy intake (in MJ/d) and protein intake (in g/d) were estimated with use of a food-frequency questionnaire. Body mass index (BMI; in kg/m(2)) and C-reactive protein concentrations (in mg/L) were also measured. Multiple logistic regression models by ethnic group were used.

RESULTS

There were no significant differences between Hispanics and NHWs in the proportion of those with low albumin concentrations or low MAM. Hispanic diabetic women had the lowest proportion of low MAM. The risk of low serum albumin concentration was twice as high in Hispanics taking insulin as in their NHW counterparts. Among Hispanics, low albumin concentration and low BMI were associated with low MAM; female sex, low albumin concentration, high BMI, and insulin use were significantly associated with risk of functional impairment.

CONCLUSION

Type 2 diabetes is associated with poor nutritional status, muscle loss, and functional impairment among Hispanic elders.

Quality and outcomes of care for older women with chronic disease

This is the fourth in a series of six papers that will be published from the 1999 lecture series on "Quality Assessment in Women's Health Care" held at the University of Michigan School of Public Health. The lectures are presented by leaders in women's health research, and they explore key issues in the definition, measurement, and improvement of quality in women's health services. The series is supported by an unrestricted educational grant from Pfizer Inc. and is presented by the Interdepartmental Concentration in Reproductive and Women's Health at the University of Michigan School of Public Health; the University of Michigan National Center of Excellence in Women's Health; and the Michigan Initiative for Women's Health. The series coordinator is Carol S. Weisman, PhD, and Catherine L. Maroney prepared the summary of the discussants' comments.

Mobility limitations in the Swedish population from 1968 to 1992: age, gender and social class differences

Mobility limitations are closely related to disability in old age. The study of mobility limitations in the population may improve the understanding of the development of disability, as well as gender and class patterns in disability in old age. Representative samples of the Swedish population between the ages of 18 and 75 years were interviewed in 1968, 1974, 1981, and 1991. A further sample of people aged 76+ years was interviewed in 1992. The questionnaire included the ability to walk 100 meters, to walk up and down stairs, and to run 100 meters. Mobility limitations begin to appear around age 40 years, and increase with age. In 1992 nearly none in the oldest age group (85+) could run 100 meters, and less than half could walk 100 meters, or go up and down stairs without difficulty. Between 1968 and 1991, the proportion of people with mobility limitations was reduced by one third, with the most prominent reduction among the oldest age groups. Women were more likely to report mobility limitations compared to men at all waves; however, the gender difference decreased between 1968 and 1991. Blue-collar workers had more mobility limitations than white-collar workers, and this discrepancy did not decrease over time. Mobility limitations often begin early in life, and differences between cohorts, men and women, and social classes can be seen well before the age of 50. The results suggest that gender differences in functional limitations among elderly people may decrease in the future, while social class inequalities are likely to persist.

Does diagnostic information contribute to predicting functional decline in long-term care?

BACKGROUND

Compared with the acute-care setting, use of risk-adjusted outcomes in long-term care is relatively new. With the recent development of administrative databases in long-term care, such uses are likely to increase.

OBJECTIVES

The objective of this study was to determine the contribution of ICD-9-CM diagnosis codes from administrative data in predicting functional decline in long-term care.

RESEARCH DESIGN

We used a retrospective sample of 15,693 long-term care residents in VA facilities in 1996.

METHODS

We defined functional decline as an increase of > or =2 in the activities of daily living (ADL) summary score from baseline to semiannual assessment. A base regression model was compared to a full model enhanced with ICD-9-CM codes. We calculated validated measures of model performance in an independent cohort.

RESULTS

The full model fit the data significantly better than the base model as indicated by the likelihood ratio test (chi2 = 179, df = 11, P <0.001). The full model predicted decline more accurately than the base model (R2 = 0.06 and 0.05, respectively) and discriminated better (c statistics were 0.70 and 0.68). Observed and predicted risks of decline were similar within deciles between the 2 models, suggesting good calibration. Validated R2 statistics were 0.05 and 0.04 for the full and base models; validated c statistics were 0.68 and 0.66.

CONCLUSIONS

Adding specific diagnostic variables to administrative data modestly improves the prediction of functional decline in long-term care residents. Diagnostic information from administrative databases may present a cost-effective alternative to chart abstraction in providing the data necessary for accurate risk adjustment.

Selecting target conditions for quality of care improvement in vulnerable older adults

OBJECTIVE

To identify a set of geriatric conditions as optimal targets for quality improvement to be used in a quality measurement system for vulnerable older adults.

DESIGN

Discussion and two rounds of ranking of conditions by a panel of geriatric clinical experts informed by literature reviews.

METHODS

A list of 78 conditions common among vulnerable older people was reduced to 35 on the basis of their (1) prevalence, (2) impact on health and quality of life, (3) effectiveness of interventions in improving mortality and quality of life, (4) disparity in the quality of care across providers and geographic areas, and (5) feasibility of obtaining the data needed to test compliance with quality indicators. A panel of 12 experts in geriatric care discussed and then ranked the 35 conditions on the basis of the same five criteria. We then selected 21 conditions, based on panelists' iterative rankings. Using available national data, we compiled information about prevalence of the selected conditions for community-dwelling older people and older nursing home residents and estimated the proportion of inpatient and outpatient care attributable to the selected conditions.

RESULTS

The 21 conditions selected as targets for quality improvement among vulnerable older adults include (in rank order): pharmacologic management; depression; dementia; heart failure; stroke (and atrial fibrillation); hospitalization and surgery; falls and mobility disorders; diabetes mellitus; end-of-life care; ischemic heart disease; hypertension; pressure ulcers; osteoporosis; urinary incontinence; pain management; preventive services; hearing impairment; pneumonia and influenza; vision impairment; malnutrition; and osteoarthritis. The selected conditions had mean rank scores from 1.2 to 3.8, and those excluded from 4.6 to 6.9, on a scale from 1 (highest ranking) to 7 (lowest ranking). Prevalence of the selected conditions ranges from 10 to 50% among community-dwelling older adults and from 25 to 80% in nursing home residents for the six most common selected conditions. The 21 target conditions account for at least 43% of all acute hospital discharges and 33% of physician office visits among persons 65 years of age and older. Actual figures must be higher because several of the selected conditions (e.g., end-of-life care) are not recorded as diagnoses.

CONCLUSIONS

Twenty-one conditions were selected as targets for quality improvement in vulnerable older people for use in a quality measurement system. The 21 geriatric conditions selected are highly prevalent in this group and likely account for more than half of the care provided to this group in hospital and ambulatory settings.

Asymptomatic peripheral arterial disease is independently associated with impaired lower extremity functioning: the women's health and aging study

BACKGROUND

We report the implications of asymptomatic lower extremity peripheral arterial disease (PAD) for lower extremity functioning among participants in the Women's Health and Aging Study, an observational study of disabled women > or = 65 years of age living in and around Baltimore.

METHODS AND RESULTS

The ankle brachial index (ABI) and measures of upper and lower extremity functioning were measured among study participants. Of 933 women with ABI < or =1. 50, 328 (31%) [corrected] had an ABI <0.90, consistent with PAD. Sixty-three percent of PAD participants had no exertional leg pain. Among participants without exertional leg pain, lower ABI levels were associated with slower walking velocity, poorer standing balance score, slower time to arise 5 times consecutively from a seated position, and fewer blocks walked per week, adjusting for age, sex, race, cigarette smoking, and comorbidities. ABI was not associated independently with measures of upper extremity functioning.

CONCLUSIONS

Asymptomatic PAD is common and is independently associated with impaired lower extremity functioning. In addition to preventing cardiovascular morbidity and death, further study is warranted to identify effective interventions to improve functioning among the growing number of men and women with asymptomatic PAD.

Functional performance and exercise of older adults in long-term care settings

Performing functional activities and exercising are important for older adults living in long-term care settings. Participation in these activities not only improves and maintains function in older adults but also can improve physical and emotional health and quality of life. The purpose of this study was to explore the variables that influence functional performance and exercise activity in a group of nursing home residents. Participants included 59 residents in a long-term care facility. The mean age of participants was 88 +/- 6.9, and the majority were women (76%), White (97%), and unmarried (76%). Residents participated in a single face-to-face interview. Chart reviews for demographic and health information also were performed. Based on stepwise multiple regression analyses, upper and lower extremity contractures and cognitive status were the only variables that significantly influenced functional performance and accounted for 49% of the variance in function. Self-efficacy and outcome expectations were the only variables to significantly influence exercise behavior and accounted for 57% of the variance in this behavior. These findings can be used to help develop and implement effective restorative nursing care programs in long-term care settings.

Making capitated Medicare work for women: policy and research challenges

Growth in capitated Medicare has special ramifications for older women who comprise the majority of Medicare beneficiaries. Older women are more likely than men to have chronic conditions that lead to illness and disability, and they often have fewer financial and social resources to cope with these problems. Gender differences in health status have a number of important implications for the financing and delivery of care for older women under both traditional fee-for-service Medicare and capitation. The utilization of effective preventive interventions, new therapeutic interventions for the management of common chronic disorders, and more cost-effective models of chronic disease management could potentially extend the active life expectancy of older women. However, there are financial and delivery system barriers to achieving these objectives. Traditional FFS Medicare has gaps in coverage of care for chronic illness and disability that disproportionately impact women. Managed care potentially offers flexibility to allocate resources creatively, to develop new models of care, and offer enhanced benefits with lower out-of-pocket costs. However, challenges to realizing this potential under Medicare managed care with unique implications for older women include: possible gender bias in capitation payments, risk selection, inadequacy of risk adjustment models, benefit and market instability, and disenrollment patterns.

Relationship between quadriceps strength and rate of loading during gait in women

One function of skeletal muscle is to serve as the body's shock absorbers and thus dampen rates of loading during activity. The aim of this cross-sectional study was to determine the significance of muscle strength on rates of loading during gait. Thirty-seven women (mean age: 34.5 +/- 8.2 years) were solicited by advertisement and placed into one of two groups-strength-trained or sedentary-on the basis of training history. They walked (10 trials) over a 10-m walkway at a controlled speed of 1.22-1.35 m/s while the rate of loading was sampled with a 1,000-Hz force platform. Quadriceps and hamstring strength was measured at 90 degrees/s with an isokinetic dynamometer. Statistical analyses (p < 0.05) included descriptive statistics and unpaired t tests for comparison between groups. The women in the sedentary group weighed more and had significantly less concentric and eccentric strength of the quadriceps and hamstrings relative to body weight than did those in the strength-trained group. In addition, they demonstrated significantly higher rates of loading (2.21 +/- 0.15 compared with 1.75 +/- 0.08%wt/ms) than those in the strength-trained group.

Assessing Individual Outcomes during Outpatient Multidisciplinary Chronic Pain Treatment by Means of an Augmented SF-36

OBJECTIVE

To meet the growing demand for objective outcomes measurement during treatment of chronic pain, we developed an instrument to track outcomes of individual patients.

METHOD

In a 2-phase study, existing and novel outcomes instruments were applied in an interdisciplinary pain management program. In the initial phase, 408 patients were administered the Short Form 36-item questionnaire and during phase 2, 437 patients (87 of whom were followed) were given an expanded (191-item) questionnaire.

RESULTS

When applied to individual patients, the Short Form 26-item questionnaire lacked measurement reliability for assessment of treatment outcomes and sensitivity to upper extremity or facial pathology, and failed to separate limitations of work versus everyday activity. A novel group of scales derived from responses to 61 questions, including the Short Form 36-item questionnaire, proved sufficiently reliable for routine follow-up of individual chronic pain patients.

CONCLUSIONS

This new Treatment Outcomes in Pain Survey allows assessment of individual patient outcomes, and aggregate or individual clinician performance, during interdisciplinary treatment of chronic pain.

Understanding what motivates older adults to exercise

The purposes of this study were to explore the factors that influenced adherence to an exercise program for older adults, and compare differences in motivation, efficacy expectations, health status, age, functional performance, and falls between adherers and nonadherers. A combined qualitative and quantitative design was used. Participants included 23 of the 24 members of an existing walking group, with an average age of 81 +/- 7.2 years. Fourteen (60%) participants did not adhere to walking, while 9 (40%) adhered. Those that adhered had fewer functional limitations due to their health, (F = 7.7, p < .05), better functional performance (F = 4.0, p < .05), stronger self-efficacy expectations related to exercise (F = 4.3, p < .05), and fewer falls (F = 4.4, p < .05). Six major themes were identified that impacted adherence: a) beliefs about exercise; b) benefits of exercise; c) past experiences with exercise; d) goals; e) personality; and f) unpleasant sensations associated with exercise. Interventions that focus on teaching older adults about the benefits of exercise, establishing appropriate goals, and decreasing unpleasant and increasing pleasant sensations associated with exercise may be useful to improve adherence to a regular exercise program.

Increased serum C reactive protein may reflect events that precede radiographic progression in osteoarthritis of the knee

OBJECTIVE

Raised serum C reactive protein (CRP) and hyaluronate (HA) concentrations predict the progression of knee osteoarthritis (OA) in the long term but the consistency of these relations with time is unknown. The purpose of this work was therefore to determine if raised CRP and HA at entry and three years before entry (-3 years) predict radiological progression of knee OA in a group of patients between entry and five years.

METHODS

Knee radiographs from 90 patients with knee OA at entry and five years follow up were assessed for progression of disease over five years. The concentrations of serum CRP and HA were measured at entry (n=90) and also in 40 serum samples available from -3 years. Odds ratios (OR) for predicting progression were calculated by logistic regression.

RESULTS

Serum CRP at entry was not predictive of progression between entry and five years (OR 1.12, 95% CI 0.81, 1.55) but serum CRP at -3 years was predictive of progression (OR 1.90, 95% CI 1.01, 3.28). Serum HA concentration at entry predicted progression between entry and five years (OR 2.32, 95% CI 1.16, 4.66).

CONCLUSION

These results are consistent with previous reports relating to HA, and suggest that raised serum CRP reflects events that precede a period of later radiographic progression in knee OA. However, because of the large overlap between groups, the serum CRP or HA concentration are not good predictors of individual patient progression and have a poor sensitivity and specificity.

Health, function and survival of a cohort of very old Canadians: results from the second wave of the Canadian Study of Health and Aging

Seniors 85 years of age and older (85+) make up the fastest-growing segment of the Canadian population. There is a need for longitudinal data on the health status of this group. We used data collected as part of the Canadian Study of Health and Aging to examine how health status changed over five years in a large (n = 1799) cohort of Canadians 85+. By the time of the follow-up assessment, 60.1% had died and 33.9% of those who had been residing in the community when the cohort was initially formed had been institutionalized. Most (79.2%) of the community survivors felt that their health had stayed the same or improved, even though over two thirds (67.9%) reported a decline in their functional abilities. Potential predictors of both good and adverse outcomes were explored. While disease prevention, health promotion and environmental modifications may decrease the personal and societal impacts of these age-associated findings, health care planning for the very old should take these data into account.

Evidence for decline in disability and improved health among persons aged 55 to 70 years: the Framingham Heart Study

OBJECTIVES

This study detected secular change in disability and health among persons aged 55 to 70 years, the life period when increases in disability and morbidity begin and retirement occurs.

METHODS

Cross-sectional comparisons were completed with data from similarly aged members of the original (n = 1760) and offspring (n = 1688) cohorts of the Framingham Heart Study, which represent 2 generations. Analyses were conducted by gender and on chronic disease subgroups by logistic regression.

RESULTS

There was substantially less disability in the offspring cohort than in the original cohort. Thirty-six percent of offspring men were disabled vs 52% of original cohort men (P = .001); among women, these proportions were 54% vs 72% (P = .001). Fewer offspring perceived their health as fair or poor and fewer had chronic diseases. Offspring were more physically active and less likely to smoke or consume high amounts of alcohol, but their average weight was greater. The secular decline in disability was strongly evident among individuals with chronic diseases.

CONCLUSIONS

Our findings depict a secular change toward a less disabled and globally healthier population in the period of life when retirement occurs.

Reliability and validity of the EuroQol in patients with osteoarthritis of the knee

OBJECTIVE

To assess the reliability and validity of the EuroQol (EQ-5D) for osteoarthritis of the knee (OA knee).

METHODS

Eighty-two patients with OA knee were asked to complete on two occasions, separated by 1 week, the EQ-5D, the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index and the 36-item short form of the Medical Outcomes Study (SF-36).

RESULTS

In this patient population, < 10% of the 243 EQ-5D health states were active. The EQ-5D demonstrated a non-Gaussian distribution. Reliability [intraclass correlation coefficient (ICC) = 0.70] is acceptable for aggregate level data. There were significant rank correlations with both the WOMAC and SF-36.

CONCLUSIONS

This study provides some evidence of EQ-5D construct validity and reliability. However, the restricted and non-normal distribution of scores, the marked difference between patients' self evaluation and derived societal utility tariffs, as well as the lack of discriminative ability for patients with 'moderate' morbidity within each of the five EQ-5D dimensions, are of concern.

The prevalence of functional disability in activities of daily living and instrumental activities of daily living among elderly Beijing Chinese

In order to assess the prevalence of the functional disability defined by activity of daily living (ADL) and instrumental activity of daily living (IADL) and associated factors in elderly Chinese, a population-based cross-sectional study was performed in urban, plain rural and mountain rural regions of Beijing. Of the 3440 subjects, 1707 are males and 1733 are females, with mean age of 71.4+/-7.7 years. Demographic, socio-economic and health aspects were obtained by trained interviewers. The results showed functional disability prevalence was 6.5% on ADL and 7.9% on IADL. Among the three representative areas in Beijing, the plain rural had the highest disability rate, increasing with the progression of age. Bathing and doing heavy housework were the two most difficult functional tasks. The functional disabilities were associated with gender and marital status. Our data suggest that plain rural elderly are most likely to generate functional disability, and bathing and doing heavy housework are two promising predictors to monitor the development of functional disability in the elderly.

Mortality from dementia in advanced age: a 5-year follow-up study of incident dementia cases

Five-year follow-up of a community-based, 77+ old cohort including incident dementia cases was used to evaluate the impact of dementia on the risk of death, taking into account other chronic conditions potentially related to death, and contrasting Alzheimer's disease (AD), and vascular dementia (VaD). In this population, 70% of the dementia cases died during the five years after diagnosis, with a mortality rate specific for dementia of 2.4 per 100 person-years. After controlling for sociodemographic variables and comorbidity, 14% of all deaths could be attributed to dementia with a risk of death among demented subjects twice as high as that for non-demented people. Mortality risk ratios were 2.0 (95% confidence interval 1.5-2.7) for AD and 3.3 (95% confidence interval 2.0-5.3) for VaD. This study confirms that dementing disorders are a major risk factor for death. Even in the oldest old (85+), dementia shortens life, especially among women.

Predictors of mortality in patients with Alzheimer's disease living in nursing homes

OBJECTIVES

To identify factors associated with mortality in patients with Alzheimer's disease, and to evaluate whether these factors vary according to severity of cognitive impairment.

METHODS

Data were from the SAGE database which includes information on all residents admitted between 1992 and 1995 to all Medicare/ Medicaid certified nursing homes of five US states. We conducted a longitudinal follow up study (median 23 months) on 9264 patients aged 65 years and above with a diagnosis of Alzheimer's disease. Patient data including demographic characteristics, dementia severity, comorbidity, and other clinical and treatment variables were collected with the Minimum Data Set. Information on death was derived through linkage to Medicare files. Baseline characteristics were used to predict survival in univariate and multivariate Cox proportional hazard models.

RESULTS

Overall mortality rate was 50%, with a first year rate of 25.7%. Increased age (risk ratio (RR) 1. 83; 95% confidence interval (95% CI) 1.65-2.03, for patients 85+ years), male sex (RR 1.81; 95% CI 1.70-1.94), limitation in physical function (RR 1.45; 95% CI 1.27-1.66), a condition of malnutrition (RR 1.31; 95%CI 1.23-1.39), the presence of pressure ulcers (RR 1.24; 95% CI 1.13-1.36), a diagnosis of diabetes mellitus (RR 1.32; 95% CI 1.21-1.43), and of cardiovascular diseases (RR 1.22; 95% CI 1. 14-1.30) were independent predictors of death, regardless of the severity of baseline dementia. Sensory problems (hearing and vision) and urinary incontinence were associated with increased mortality only among patients with less severe dementia. The presence of disruptive behaviour, aphasia, and a diagnosis of Parkinson's disease were not related to survival. African-Americans and other minority groups were less likely to die relative to white people.

CONCLUSIONS

Age, sex, functional limitation, and malnutrition seem to be the strongest predictors of death for patients with Alzheimer's disease in nursing homes. Altogether, severity of dementia has no influence on survival, yet the predictive role of certain variables depends on the degree of impairment. Minority groups have a reduced risk of death relative to white people.

Heart failure in community-dwelling older persons: aims, design and adherence rate of the ICARe Dicomano project: an epidemiologic study. Insufficienza Cardiaca negli Anziani Residenti a Dicomano

BACKGROUND

The prevalence of heart failure (HF) increases with age, and HF is a major cause of disability and mortality in older persons. Detection of HF in epidemiological studies has relied on criteria validated only in young and middle-age adults, and, therefore, may prove inadequate in older subjects, because they do not take into account the pathophysiologic and clinical peculiarities of HF in old age. Thus, the true prevalence of HF in the older general population remains uncertain and has probably been underestimated in previous studies. Moreover, the mechanism and the extent by which HF hinders physical functioning in older people has not been fully elucidated.

OBJECTIVES

This paper describes the design of the ICARe study, carried out in an older home-dwelling population to collect data about: (1) the sensitivity and specificity of diagnostic criteria used previously in epidemiological studies of HF; (2) the prevalence of the different pathophysiologic forms of HF; and (3) the impact of HF on overall health status, and on physical functioning, in the absence or presence of chronic comorbidity.

DESIGN AND SETTING

This was a cross-sectional survey. Eligible were all community-dwelling persons aged 65 years or older recorded in the Registry Office of Dicomano, a small town nearby Florence (Italy). All the domains of multidimensional geriatric assessment were explored through different phases of the study (home interview, laboratory testing, geriatric visit) that comprised an extensive cardiopulmonary instrumental assessment including: color Doppler echocardiography, echotomography of the carotid arteries used in an original method to determine arterial compliance, and bell spirometry. Presence of major chronic conditions was ascertained by predefined, standard algorithms that were based largely on clinical examination.

RESULTS

There were 864 older persons eligible for the ICARe study. Even with a substantial decline from home interview (91.2%) to the cardiopulmonary study (71.1%), the adherence rate remained high throughout the study, and the population examined was fairly representative of the original eligible population. Thus, we believe that the data collected in this study offer a unique opportunity to assess the validity of the diagnostic clinical criteria for HF in the general older population, to identify the pathophysiology underlying the syndrome, and to investigate the relationship between HF, comorbidity, and disability.

Methods and prevalence of ADL limitations in Hispanic and non-Hispanic white subjects in rural Colorado: the San Luis Valley Health and Aging Study

PURPOSE

The Hispanic population in the United States is the fastest growing minority group, yet there is little understanding of the disability patterns that occur as this population ages. We conducted a cross-sectional study to define the prevalence of limitations of activities of daily living (ADL) and measures of observed function.

METHODS

We censussed two rural counties in southern Colorado and selected a stratified sample of both Hispanic and non-Hispanic white (NHW) residents; 81.6% completed the protocol.

RESULTS

Among the 1250 subjects aged 65 years and older, Hispanic elderly living in the community had greater ADL disability than NHW subjects, both for any difficulty (p = 0.006), and for needing assistance (p = 0.002). Hispanic persons were less likely to reside in nursing homes (3.4%) compared with NHW persons (9.3%). Hispanic elderly had excess prevalence of dependent ADL tasks (needs assistance or unable to do), (age, gender-adjusted odds ratio = 1.39, 95% CI = 1.01-1.92) in community dwelling and nursing home residents combined. There was no Hispanic excess of less severe difficulty compared with NHW persons, and there was a similar prevalence of limitation on observed functional tasks (timed walk, stooping, rising from a chair) in both groups.

CONCLUSIONS

There was a modest Hispanic excess of reported dependent ADL limitation, and no excess of observed functional difficulties. Hispanics enter older age with much less income and education, yet they do not have a marked excess prevalence of limitations in activities of daily living when compared with NHW persons living in the same area.

Leg symptoms, the ankle-brachial index, and walking ability in patients with peripheral arterial disease

OBJECTIVE

To determine how functional status and walking ability are related to both severity of lower extremity peripheral arterial disease (PAD) and PAD-related leg symptoms.

DESIGN

Cross-sectional study.

SETTING

Academic medical center.

PARTICIPANTS

Patients aged 55 years and older diagnosed with PAD in a blood flow laboratory or general medicine practice (n = 147). Randomly selected control patients without PAD were identified in a general medicine practice (n = 67).

MEASUREMENTS

Severity of PAD was measured with the ankle-brachial index (ABI). All patients were categorized according to whether they had (1) no exertional leg symptoms; (2) classic intermittent claudication; (3) exertional leg symptoms that also begin at rest (pain at rest), or (4) exertional leg symptoms other than intermittent claudication or pain at rest (atypical exertional leg symptoms). Participants completed the 36-Item Short-Form Health Survey (SF-36) and the Walking Impairment Questionnaire (WIQ). The WIQ quantifies patient-reported walking speed, walking distance, and stair-climbing ability, respectively, on a scale of 0 to 100 (100 = best).

MAIN RESULTS

In multivariate analyses patients with atypical exertional leg symptoms, intermittent claudication, and pain at rest, respectively, had progressively poorer scores for walking distance, walking speed, and stair climbing. The ABI was measurably and independently associated with walking distance (regression coefficient = 2.87/0.1 ABI unit, p =.002) and walking speed (regression coefficient = 2.09/0.1 ABI unit, p =.015) scores. Among PAD patients only, pain at rest was associated independently with all WIQ scores and six SF-36 domains, while ABI was an independent predictor of WIQ distance score.

CONCLUSIONS

Both PAD-related leg symptoms and ABI predict patient-perceived walking ability in PAD.

Self-reported and performance-based functional status and associated factors among elderly men: the Finnish cohorts of the Seven Countries Study

Health and functional status were studied in 470 men aged 70-89, the survivors of the Finnish cohorts of the Seven Countries Study. We aimed to compare subjective (self-reported activity of daily living [ADL]) and objective methods (four physical performance tests) in the assessment of physical function and to identify which factors are related to physical function. Poor ADL and decreased physical performance were mainly explained by the same health-related factors. The strongest determinants of ADL were depressive symptomatology odds ratio [OR] 4.8, 95% confidence interval [CI] 2.7-8.8), osteoarthritis (OR 3.3, 95% CI 1.8-5.9), vertigo (OR 2.5, 95% CI 1.2-5.5) and diabetes (OR 2.3, 95% CI 1.2-4.6). Self-reported ADL and performance-based measures were in general strongly correlated with each other, although there was some discordance owing to the fact that these performance tests examine functional limitations, whereas the self-reported ADL reflects disability. The choice of which measurement to use in assessing functional status should be based on research objectives and the type of population under study.