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

Reduced quadriceps strength relative to body weight: a risk factor for knee osteoarthritis in women?

OBJECTIVE

To determine whether baseline lower extremity muscle weakness is a risk factor for incident radiographic osteoarthritis (OA) of the knee.

METHODS

This prospective study involved 342 elderly community-dwelling subjects (178 women, 164 men) from central Indiana, for whom baseline and followup (mean interval 31.3 months) knee radiographs were available. Lower extremity muscle strength was measured by isokinetic dynamometry and lean tissue (i.e., muscle) mass in the lower extremities by dual x-ray absorptiometry.

RESULTS

Knee OA was associated with an increase in body weight in women (P = 0.0014), but not in men. In both sexes, lower extremity muscle mass exhibited a strong positive correlation with body weight. In women, after adjustment for body weight, knee extensor strength was 18% lower at baseline among subjects who developed incident knee OA than among the controls (P = 0.053), whereas after adjustment for lower extremity muscle mass, knee extensor strength was 15% lower than in the controls (P not significant). In men, in contrast, adjusted knee extensor strength at baseline was comparable to that in the controls. Among the 13 women who developed incident OA, there was a strong, highly significant negative correlation between body weight and extensor strength (r = -0.740, P = 0.003), that is, the more obese the subject, the greater the reduction of quadriceps strength. In contrast, among the 14 men who developed incident OA, a modest positive correlation existed between weight and quadriceps strength (r = 0.455, P = 0.058). No correlation between knee flexor (hamstring) strength and knee OA was seen in either sex.

CONCLUSION

Reduced quadriceps strength relative to body weight may be a risk factor for knee OA in women.

The ankle brachial index independently predicts walking velocity and walking endurance in peripheral arterial disease

OBJECTIVES

Maintaining function among older men and women is an important public health goal as the population lives longer with chronic disease. We report the relationships between lower extremity peripheral arterial disease (PAD), PAD severity, and PAD-related symptoms with walking velocity and endurance among men and women aged 55 and older.

DESIGN

A cross-sectional design.

SETTING

An academic medical center.

PARTICIPANTS

Participants with PAD were men and women aged 55 and older identified from a blood flow laboratory or a general medicine practice (n = 158). Randomly selected controls without PAD were identified from the general medicine practice (n = 70).

MEASUREMENTS

PAD was diagnosed and quantified using the ankle brachial index (ABI). Subjects were categorized according to whether they had severe PAD (ABI <0.40), mild to moderate PAD (ABI 0.40 to <0.90), or no PAD (ABI 0.90 to <1.50). Walking endurance was assessed with the 6-minute walk. Usual walking velocity and maximal walking velocity were assessed with "usual" and "maximal" paced 4-meter walks, respectively.

RESULTS

Average distances achieved in the 6-minute walk were 1569+/-390 feet for subjects with ABI 0.90-1.50, 1192+/-368 feet for subjects with ABI 0.40 to <0.90, and 942+/-334 feet for subjects with ABI < 0.40 (trend P value < .001). Walking velocities for both the usual and maximal paced 4-meter walks were slowest among subjects with ABI < 0.40 and fastest among subjects with ABI 0.90 to <1.50. Subjects with PAD who had pain at rest had slower walking velocity and poorer walking endurance than other subjects with PAD. In multiple linear regression analyses that included subjects with PAD only, ABI level was an independent predictor of 6-minute walk performance (regression coefficient = 159 ft/0.40 ABI units, P = .011), usual paced 4-meter walk (regression coefficient = .095 meters/sec/0.40 ABI units, P = .031), and maximal paced 4-meter walk (regression coefficient = .120 meters/sec/0.40 ABI units, P = .050) adjusting for age, sex, race, leg symptoms, and comorbid diseases known to affect functioning. Pain at rest was associated independently with the maximally paced 4-meter walk (-0.201 meters/sec, P = .024), but not with the other walks.

CONCLUSION

ABI level has a measurable and independent association with walking endurance and both usual and maximal walking velocity. These data suggest that PAD may impair lower extremity function by diminishing function of both Type I ("slow twitch") and Type II ("fast twitch") muscle fibers. Because walking velocity has important prognostic implications for functioning, these data also suggest that ABI may be used to identify patients at increased risk of mobility loss.

Predictors of healthy aging in men with high life expectancies

OBJECTIVE

The purpose of this study was to identify risk factors that consistently predict staying healthy in contrast to developing clinical illness and/or physical and mental impairments.

METHODS

More than 8000 men of Japanese ancestry were followed for 28 years with repeat examinations and surveillance for deaths and incident clinical illness. Physical and cognitive functions were measured in 1993. Measures of healthy aging included surviving and remaining free of major chronic illnesses and physical and cognitive impairments.

RESULTS

Of 6505 healthy men at baseline, 2524 (39%) died prior to the final exam. Of the 3263 available survivors, 41% remained free of major clinical illnesses, 40% remained free of both physical and cognitive impairment, and 19% remained free of both illness and impairment. The most consistent predictors of healthy aging were low blood pressure, low serum glucose, not smoking cigarettes, and not being obese.

CONCLUSIONS

Beyond the biological effects of aging, much of the illness and disability in the elderly is related to risk factors present at midlife.

Dementia is the major cause of functional dependence in the elderly: 3-year follow-up data from a population-based study

OBJECTIVES

The purpose of this investigation was to study the role of dementia and other common age-related diseases as determinants of dependence in activities of daily living (ADL) in the elderly.

METHODS

The study population consisted of 1745 persons, aged 75 years and older, living in a district of Stockholm. They were examined at baseline and after a 3-year follow-up interval. Katz's index was used to measure functional status. Functional dependence at baseline, functional decline, and development of functional dependence at follow-up were examined in relation to sociodemographic characteristics and chronic conditions.

RESULTS

At baseline, factors associated with functional dependence were age, dementia, cerebrovascular disease, heart disease, and hip fracture. However, only age and dementia were associated with the development of functional dependence and decline after 3 years. In a similar analysis, including only nondemented subjects. Mini-Mental State Examination scores emerged as one of the strongest determinants. The population attributable risk percentage of dementia in the development of functional dependence was 49%.

CONCLUSIONS

In a very old population, dementia and cognitive impairment make the strongest contribution to both the development of long-term functional dependence and decline in function.

Understanding trends in functional limitations among older Americans

OBJECTIVES

This report documents trends in functional limitations among older Americans from 1984 to 1993 and investigates reasons for such trends.

METHODS

We applied logistic regression to data for noninstitutionalized Americans aged 50 years and older from the Survey of Income and Program Participation. We focused on 4 functional limitation measures unlikely to be affected by changes in role expectations and living environments: reported difficulty seeing words in a newspaper, lifting and carrying 10 pounds, climbing a flight of stairs, and walking a quarter of a mile.

RESULTS

We found large declines in the crude prevalence of functional limitations, especially for those 80 years and older. Generally, changes in population composition explained only a small portion of the downward trends. Once changes in population composition and mobility-related device use were considered for difficulty walking, significant improvements in functioning remained for the 65- to 79-year-old group.

CONCLUSIONS

Changes in population composition, device use, survey design, role expectations, and living environments do not appear to account completely for improvements in functioning. We infer that changes in under-lying physiological capability--whether real or perceived--likely underlie such trends.

Functional performance of older adults in a long-term care setting

Motivation has been identified as an important factor in the older adult's ability to perform functional activities. The purpose of this study was to explore functional performance and factors that have an impact on functional performance in nursing home residents. Participants included 44 White older adults from two nursing homes. The majority of the participants were female (84%). The mean age of the participants was 88 +/- 6.4 years and, on the average, they had been institutionalized for 2.85 +/- 2.8 years. Following data reduction of the predictors, two factors--motivation (efficacy beliefs and intrinsic motivation) and lower extremity function (contractures and standing balance)--were identified. In a stepwise multiple regression analysis, these two factors were the only variables that significantly predicted functional performance and accounted for 81% of the variance in function.

Chronic conditions and disabilities among seniors: an analysis of population-based health and activity limitation surveys

PURPOSE

To describe the prevalence of disabilities and the medical conditions and risk factors associated with mobility and agility disabilities among seniors.

METHODS

In the 1986 and 1991 Canadian Census, every fifth person answered a screening question about activity limitation and disabilities. A probability sample of both those reporting and not reporting disability was selected to complete the Health and Activity Limitations Surveys (HALS) in 1986 and 1991. These two cross-sectional surveys conducted five years apart collected detailed activity limitation information about persons over 15 years of age. The current analysis was based on only respondents aged 65 years and older. The sample size for 65 years and older was 38518 in 1986 and 5106 in 1991. A computer link with the Census data provided household income and additional socio-demographic data for all respondents.

RESULTS

Over 40% of Canadian seniors reported at least one disability, and approximately a quarter of disabled seniors were classified as severely disabled. Mobility and agility disabilities accounted for over 80% of all disabilities reported by seniors, and senior women were more likely than men to report having a mobility or agility disability. Arthritis/rheumatism was reported as the cause of over 30% of all mobility and agility disabilities.

CONCLUSIONS

The continued monitoring of disabilities through surveys such as HALS will help determine the prevalence as well as aid in the identification of the causes of disabilities. Such information may be used to guide the implementation of appropriate public health interventions that will meet the changing health care needs of seniors.

Knee adduction moment, serum hyaluronan level, and disease severity in medial tibiofemoral osteoarthritis

OBJECTIVE

The adduction moment at the knee during gait is the primary determinant of medial-to-lateral load distribution. If the adduction moment contributes to progression of osteoarthritis (OA), then patients with advanced medial tibiofemoral OA should have higher adduction moments. The present study was undertaken to investigate the hypothesis that the adduction moment normalized for weight and height is associated with medial tibiofemoral OA disease severity after controlling for age, sex, and pain level, and to examine the correlation of serum hyaluronan (HA) level with disease severity and with the adduction moment in a subset of patients.

METHODS

Fifty-four patients with medial tibiofemoral OA underwent gait analysis and radiographic evaluation. Disease severity was assessed using the Kellgren-Lawrence (K-L) grade and medial joint space width. In a subset of 23 patients with available sera, HA was quantified by sandwich enzyme-linked immunosorbent assay. Pearson correlations, a random effects model, and multivariate regression models were used.

RESULTS

The adduction moment correlated with the K-L grade in the left and right knees (r = 0.68 and r = 0.60, respectively), and with joint space width in the left and right knees (r = -0.45 and r = -0.47, respectively). The relationship persisted after controlling for age, sex, and severity of pain. The partial correlation between K-L grade and adduction moment was 0.71 in the left knees and 0.61 in the right knees. For every 1.0-unit increase in adduction moment, there was a 0.63-mm decrease in joint space width. In the subset of patients in whom serum HA levels were measured, HA levels correlated with medial joint space width (r = -0.55), but not with the adduction moment.

CONCLUSION

There is a significant relationship between the adduction moment and OA disease severity. Serum HA levels correlate with joint space width but not with the adduction moment. Longitudinal studies will be necessary to determine the contribution of the adduction moment, and its contribution in conjunction with metabolic markers, to progression of medial tibiofemoral OA.

Estimates of the prevalence of arthritis and selected musculoskeletal disorders in the United States

OBJECTIVE

To provide a single source for the best available estimates of the national prevalence of arthritis in general and of selected musculoskeletal disorders (osteoarthritis, rheumatoid arthritis, juvenile rheumatoid arthritis, the spondylarthropathies, systemic lupus erythematosus, scleroderma, polymyalgia rheumatica/giant cell arteritis, gout, fibromyalgia, and low back pain).

METHODS

The National Arthritis Data Workgroup reviewed data from available surveys, such as the National Health and Nutrition Examination Survey series. For overall national estimates, we used surveys based on representative samples. Because data based on national population samples are unavailable for most specific musculoskeletal conditions, we derived data from various smaller survey samples from defined populations. Prevalence estimates from these surveys were linked to 1990 US Bureau of the Census population data to calculate national estimates. We also estimated the expected frequency of arthritis in the year 2020.

RESULTS

Current national estimates are provided, with important caveats regarding their interpretation, for self-reported arthritis and selected conditions. An estimated 15% (40 million) of Americans had some form of arthritis in 1995. By the year 2020, an estimated 18.2% (59.4 million) will be affected.

CONCLUSION

Given the limitations of the data on which they are based, this report provides the best available prevalence estimates for arthritis and other rheumatic conditions overall, and for selected musculoskeletal disorders, in the US population.

Prognostic factors in very old demented adults: a seven-year follow-up from a population-based survey in Stockholm

OBJECTIVE

To detect prognostic factors in very old demented subjects with Alzheimer's disease (AD), vascular dementia (VaD), and other types of dementia (OD).

DESIGN

Follow-up clinical examinations of dementia patients from a population-based study after 3- and 7-year intervals.

SETTING AND PARTICIPANTS

In an established population aged 75 years and older in Stockholm, Sweden, there were 133 cases of AD, 52 of VaD, and 38 of OD.

MAIN OUTCOME MEASURES

Predictors of survival at 3- and 7-year follow-up examinations were evaluated by Cox proportional hazard models. Progression was measured as the annual rate of change in Mini-Mental State Examination (MMSE) scores. Linear models were used to evaluate predictors of progression.

RESULTS

Older age, male gender, low education, comorbidity, and functional disability predicted shorter 7-year survival in the 223 prevalent dementia cases. Other factors, including type of dementia, dementia severity, and duration of the disease were not significant. The average rate of cognitive decline in the 81 mild to moderate demented subjects who survived 3 years was 2.4 MMSE points per year. Type of dementia (AD vs OD), higher baseline cognitive function, and greater functional disability predicted faster decline. Despite similar survival probability, predictors of death varied as a function of dementia type: Older age (for AD and VaD), comorbidity (for AD and OD), and functional dependency (for VaD). In AD, prognostic factors were similar to those described for the combined dementia groups, with the exception of an accelerated cognitive decline among women.

CONCLUSIONS

Although methodological difficulties exist, it is possible to identify demented subjects with worse prognoses (shorter survival and faster cognitive decline) by using clinical and demographic data. Clinicians and healthcare planners should be aware of the potential usefulness of functional dependence as a prognostic indicator. Finally, the need for careful clinical examinations of demented subjects is stressed by the increased mortality found among those demented who are also affected by other chronic conditions.

Lower-extremity functioning in older Mexican Americans and its association with medical problems

OBJECTIVE

To describe lower-extremity functioning in community-dwelling older Mexican Americans and to examine its relationship with medical problems.

DESIGN

Cross-sectional analyses of survey and performance-based data obtained in a population-based study employing area probability sampling.

SETTING

Households within selected census tracts of five Southwestern states: Arizona, California, Colorado, New Mexico, and Texas.

PARTICIPANTS

A total of 2873 Mexican Americans aged 65 years and older.

MEASUREMENTS

A multidimensional questionnaire assessing demographic, sociocultural, and health variables. Standardized tests of lower-extremity physical functioning included measures of standing balance, repeated chair stands, walking, and an overall summary measure.

RESULTS

Regression analyses revealed that being more than age 75 and female, having arthritis diabetes, visual impairments, or being obese or underweight were all significantly associated with performance on both individual and summary tests of lower-extremity functioning. In separate regression analyses, the total number of medical conditions was also associated with performance.

CONCLUSIONS

The likelihood of predicting performance or inability to complete tests of lower-extremity functioning was greatest for those aged 80 and older, those with arthritis or diabetes, and those with three or more medical conditions. Because of the high prevalence of diabetes in Mexican Americans, documentation of the association of diabetes with performance-based tests of lower-extremity functioning may help guide early interventions targeted to prevent progression to more severe limitations or disability.

Functional abilities of elderly coronary heart disease patients

The impact of coronary heart disease (CHD) on elderly patients' functional abilities is of growing interest because of the increasing number of people that survive the disease. The aim of our study was, firstly, to describe functional abilities among elderly CHD patients and, secondly, to analyze the relationships between physical disability and the severity of chest pain or dyspnea. The third aim was to assess whether there is an independent association between physical disability and CHD. The study was carried out at the health center of the municipality of Lieto, southwestern Finland. From a population of 1196 community-dwelling persons aged > or = 64 years, 89 men and 73 women with CHD (angina pectoris and/or a past myocardial infarction) were selected along with 178 male and 146 female sex- and age-matched controls without CHD. Physical functioning was assessed by means of interviewer-based questionnaires, compared between patients and controls and described in relation to the severity of chest pain and dyspnea among patients. The associations between dependence or difficulties in mobility, ADL (activities of daily living) and IADL (instrumental activities of daily living) and CHD, age, smoking, comorbidities, drug therapy and clinical characteristics were assessed by logistic regression analyses. On items representing mobility and managing in IADL, patients reported more difficulties or dependence than controls. Among female patients, more severe chest pain was associated with poor managing in IADL and tended to be associated with poor mobility. More severe dyspnea was associated with poor mobility among both male and female patients, and with poor managing in IADL among male patients. Logistic regression analyses failed to show that CHD was associated independently with physical disability among the elderly. However, physical disability was associated with the use of cardiovascular drugs in the models among both genders, which probably indirectly indicated an association between physical disability and CHD. Several confounding factors, such as higher age, depression, cancer and the use of psychotropic drugs, contributed to the decline in functional abilities even among persons with CHD. In conclusion, elderly CHD patients have greater limitations in their functional ability than matched controls, which may depend on the severity of the disease. Especially male patients' limitations in physical abilities may be influenced by the fact that men with CHD are more likely to be depressed. Although an independent association between physical disability and CHD was not found, the associations found between physical disability and the use of cardiovascular drugs probably indicate a causal relationship between CHD and physical disability.

Preadmission psychosocial screening of older orthopedic surgery patients: evaluation of a Social Work Service

A preadmission social work intervention was evaluated for impact on length of hospital stay (LOS) and patient satisfaction. Psychosocial issues related to function and post-discharge needs were assessed at an exploratory level. A modified post-test only control group design was used. Study group patients were screened before hospitalization and offered services on admission. Control group patients received standard care. Study group patients were significantly more satisfied with services but impact on length of stay was not demonstrated with one possible exception. Post-operative complications were significantly related to longer LOS; however, unlike control group patients, study group patients with complications did not have significantly longer LOS. Women and those limited in preadmission physical function were most likely to report insufficient help after discharge. A more intensive preadmission intervention is recommended to improve impact on LOS and informal support system involvement, while future outcome studies would clarify the nature of service gaps and high risk groups.

The effect of specific medical conditions on functional decline

OBJECTIVES

To examine how functional status among older community-dwelling residents differs over time between those with and those without specific medical conditions.

DESIGN

Prospective cohort study.

PARTICIPANTS

A total of 1060 community-dwelling Massachusetts residents aged 65 or older who were not totally functionally dependent at baseline assessment.

MEASUREMENTS

Functional status, five medical conditions (heart problem, arthritis, diabetes, cancer, and stroke), and the total number of these five medical conditions. Assessments were done at baseline and at two annual follow-ups.

RESULTS

Adjusted repeated measures analysis of covariance revealed a time difference (P < .001) for all five medical conditions and group differences for diabetes (P = .006) and stroke (P < .001). Functional abilities declined over time and those with specific medical conditions were more impaired initially, but the rate of decline did not significantly differ from those free of the condition. The presence of each additional medical condition resulted in additional impairment (P < .001), but the rate of decline over time did not differ by number of medical conditions.

CONCLUSIONS

Efforts to reduce or prevent the development of specific medical conditions are essential to maintaining functional independence of older people as well as to reducing use of supportive services and admission rates to nursing homes. Particular attention should be directed toward preventing stroke since its consequences are the most functionally disabling.

Do disease specific characteristics add to the explanation of mobility limitations in patients with different chronic diseases? A study in The Netherlands

STUDY OBJECTIVES

To determine whether disease specific characteristics, reflecting clinical disease severity, add to the explanation of mobility limitations in patients with specific chronic diseases.

DESIGN AND SETTING

Cross sectional study of survey data from community dwelling elderly people, aged 55-85 years, in the Netherlands.

PARTICIPANTS AND METHODS

The additional explanation of mobility limitations by disease specific characteristics was examined by logistic regression analyses on data from 2830 community dwelling elderly people.

MAIN RESULTS

In the total sample, chronic non-specific lung disease, cardiac disease, peripheral atherosclerosis, diabetes mellitus, stroke, arthritis and cancer (the index diseases), were all independently associated with mobility limitations. Adjusted for age, sex, comorbidity, and medical treatment disease specific characteristics that explain the association between disease and mobility mostly reflect decreased endurance capacity (shortness of breath and disturbed night rest in chronic non-specific lung disease, angina pectoris and congestive heart failure in cardiac disease), or are directly related to mobility function (stiffness and lower body complaints in arthritis). For atherosclerosis and diabetes mellitus, disease specific characteristics did not add to the explanation of mobility limitations.

CONCLUSIONS

The results provide evidence that, to obtain more detailed information about the differential impact of chronic diseases on mobility, disease specific characteristics are important to take into account.

Heart health in older adults. Import of heart disease and opportunities for maintaining cardiac health

Coronary heart disease remains the leading cause of morbidity and mortality in older adults, despite improved survival and declining mortality. This article describes the prevalence and impact of heart disease on people's lives, singly and in combination with other diseases. It then reviews current findings as to the risk factors for CHD in older adults and the underlying physiologic changes of aging plus pathophysiologic changes of hypertension and CHD in impairing the ability of older adults to respond to exercise and other stressors, and the effects of exercise training in attenuating the adverse cardiovascular changes of aging. This information provides a basis for considering opportunities for prevention of heart disease and maximizing heart function. The article concludes by describing the known contribution of preventive measures to declines in heart disease in older adults.

The contribution of six chronic conditions to the total burden of mobility disability in the Dutch population

OBJECTIVES

This study assessed the proportions of the burden of mobility disability in the Dutch population that are attributable to musculoskeletal diseases, lung diseases, neurological disorders, heart diseases, diabetes, and cancer.

METHODS

National survey data were analyzed with an elimination technique that combines the results of logistic regression analysis and the disease prevalence.

RESULTS

Of the total prevalence of disability (20.5%), 33.7% can be attributed to these six chronic conditions. Musculoskeletal disorders account for the major part, whereas the contribution of cancer is very small.

CONCLUSIONS

The potential benefits of effective curative or preventive treatments for chronic conditions, in terms of reduction of the disability burden in the population, are limited.

Effects of self-care education on the health status of inner-city patients with osteoarthritis of the knee

OBJECTIVE

To evaluate a concise program of self-care education delivered by an arthritis nurse specialist as an adjunct to primary care for inner-city patients with knee osteoarthritis (OA).

METHODS

An attention-controlled clinical trial; 211 inner-city patients with knee OA were assigned arbitrarily to education (E) or attention-control (AC) conditions. Group E received an individualized 30-60-minute educational intervention that emphasized nonpharmacologic management of joint pain, preservation of function by problem-solving, and practice of principles of joint protection. Brief telephone contacts 1 week and 4 weeks later monitored and reinforced new self-care activities. Group AC viewed a 20-minute standardized public education presentation on arthritis and received followup telephone calls (only to encourage continued participation in the study). Outcomes included the Health Assessment Questionnaire (HAQ) Disability and Discomfort Scales, 10-cm visual analog scales measuring knee pain at rest and while walking, and the Quality of Well-Being (QWB) scale. Assessments were made at baseline and at 4-month intervals for 1 year.

RESULTS

A total of 165 subjects (78%) completed all assessments. After control for baseline status, group E had significantly lower scores for disability and resting knee pain throughout the year of postintervention followup (P < 0.05 for both). Effects were somewhat discordant. By 12 months, functional benefits had begun to wane, while the effect on resting knee pain had grown. The overall effects of education on walking knee pain, overall joint pain (by HAQ), and general health status (by QWB) were not significant.

CONCLUSION

Self-care education for inner-city patients with knee OA, delivered as an adjunct to primary care, was found to result in notable preservation of function and control of resting knee pain. The magnitude of the observed effects compares well with those of more labor-intensive and time-consuming intervention models. However, more sustained preservation of function and consistent effects on pain may require prolonged, more proactive followup, either by the patient educator or by a trained clinical assistant dedicated to the task of supporting self-care by patients with knee OA.

Is knee joint proprioception worse in the arthritic knee versus the unaffected knee in unilateral knee osteoarthritis?

OBJECTIVE

Neuromuscular joint protection requires proprioceptive input and motor output. Impairment of proprioception in knee osteoarthritis (OA) may contribute to, and/or result from, the disease. If this impairment was exclusively a local result of OA, a between-knee difference would be expected in patients with unilateral OA (UOA). To explore causal directions, 2 hypotheses were tested: 1) proprioception is worse in UOA patients versus elderly controls; 2) proprioception is worse in the arthritic knee versus the unaffected knee in UOA patients.

METHODS

Twenty-eight UOA patients (Kellgren-Lawrence grade > or =2 in 1 knee and <2 in the other knee) and 29 elderly controls were enrolled. The unaffected knee of each UOA patient and both knees of the elderly controls were required to meet symptom, examination, and radiographic criteria. Proprioception (detection threshold of joint displacement after slow, passive, automated knee motion), body mass index, pain, functional status, range of motion, and laxity were measured.

RESULTS

UOA patients had worse proprioception than did elderly controls, in either knee. A between-knee difference was not found in UOA patients.

CONCLUSION

Impaired proprioception is not exclusively a local result of disease in knee OA. The relative importance of impaired proprioception in the development and progression of knee OA will require longitudinal study.

Differential relationships of risk factors to alternative measures of disability

The purpose of this article was to determine whether risk factors for four dimensions of disability differ and whether it is legitimate to use aggregated disability measures in risk factor analyses. Using data from the baseline Duke Established Populations for Epidemiologic Studies of the Elderly survey (n = 4,162), the authors examined four measures of disability--basic activities of daily living (ADLs), household ADLs, advanced ADLs, and mobility--and an aggregated measure consisting of these four measures summed. Sociodemographic risk factors were examined using stagewise multivariate regression analysis for the five measures of disability. Weighted least squares with an arbitrary distribution function estimator were used to determine differences in each risk factor's performance across the unaggregated measures. Risk factors varied in strength, presence, and direction of impact across the four dimensions of disability; as a result, analyses using an aggregated measure were misleading.

The Bristol 'OA500' study: progression of osteoarthritis (OA) over 3 years and the relationship between clinical and radiographic changes at the knee joint

Five hundred patients with established, symptomatic limb joint OA have been recruited into an on-going prospective study of the natural history of the condition. Four hundred and fifteen patients (mean age 65.6 years, female to male ratio 2.05:1) were available for a full clinical and radiographic review 3 years after entry (mean entry to follow-up interval 37.6 months, range 31-41). The majority reported an overall worsening of their condition, although pain severity did not change. There was an overall increase in disability (Steinbrocker) and the use of walking aids in the group but 57 patients (13.7%) improved, 38 of whom had undergone joint surgery. There was a strong correlation between changes in different clinical outcome measures, but none of the baseline variables predicted change over 3 years with the exception of an association between pain severity and subsequent surgery. One hundred and ninety-three of the 415 patients had knee joint disease at entry. One hundred and forty-five of these patients had knee radiographs and full clinical data available from both time points. Some change was seen in 85 of 276 evaluable tibiofemoral joints (30.1%), but only 10 patellofemoral joints. There was a strong correlation between changes in joint space, osteophyte and subchondral bone scelerosis. However, there was no correlation between radiographic and clinical changes. It is concluded that radiographic change may not be a good surrogate for clinical outcome in established OA. This has implications for the design of long-term studies of possible structure modifying agents in OA.

Outcomes for older men and women with congestive heart failure

OBJECTIVES

To describe and compare outcomes for men and women discharged alive following a hospitalization for congestive heart failure (CHF).

DESIGN

Prospective cohort study.

PARTICIPANTS

A total of 519 patients, aged > or = 65, who were discharged alive after a hospitalization for CHF (DRG = 127).

MEASUREMENTS

Outcomes (Activities of Daily Living (ADLs), shortness of breath when walking, perceived health, living situation, rehospitalization, and mortality) were measured at 3 times (6 weeks, 6 months, and 1 year) post-discharge.

RESULTS

The 205 men were, on average, younger (77 +/- 7 vs 80 +/- 8, P < .001), wealthier (46% vs 21% earned > or = $10,000, P < .001), and more often married (50% vs 19%, P < .001). Men were more likely than women to have a previous history of CHF (71% vs 63%, P = .052). Men also had higher 1-year mortality than women (48% vs 35%, P = .009), even after adjusting for age, comorbidity, physiological severity (APACHE II APS and RAND discharge instability), radiological evidence of CHF, prior ADLs, walking ability, living situation, and perceived health. Men and women survivors at 1-year had similar and substantial impairment for all non-fatal outcomes considered (all P values > or = .489). Their adjusted mean ADL scores were consistent with complete dependence on one essential activity (range 0-6 dependencies); 35% were short of breath walking less than 1 block; 62% had fair or poor perceived health; 32% received some formal care; and 46% were rehospitalized within 1 year of discharge.

CONCLUSIONS

Men with CHF have a higher mortality than women with CHF. Men and women who survive have similar and substantial impairment for all non-fatal outcomes (ADLs, shortness of breath upon walking, perceived health, living situation, and rehospitalization).

The rhetorics and realities of community health care: the limits of countervailing powers to meet the health care needs of the twenty-first century

As the paradox of medical success leaves behind more chronicity, policy makers around the world increasingly focus on community-based programs both to address chronic health problems and to prevent major disorders. This essay presents my comparative sociological framework of ideal-type models for understanding the countervailing powers that underlie and shape different kinds of heath care systems and their limitations in addressing the health care needs of the twenty-first century. In this context, I then analyze the revival of community health care rhetoric in the United States and compare it to the realities in which it operates. The realities of institutional power, fragmentation in funding, illness as a private condition and health care as a private good, the lack of societal commitment, competition, and the waning of community cohesion all suggest that communal democracy will be difficult to achieve. Current successes require further investigation. Examples from abroad suggest, ironically, that community health care develops best if the state and health professionals make a deep commitment to it, against their own immediate interests but for their enlightened self-interest.

Does family support buffer the impact of specific chronic diseases on mobility in community-dwelling elderly?

The present study explores whether different structural (presence of partner and children) and functional (amounts of instrumental and emotional support provided by partner and children) family characteristics buffer the influence of chronic diseases on physical functioning. Logistic regression analyses were performed in a population-based sample of 2830 community-dwelling elderly people with chronic diseases as independent variable, and mobility difficulties as dependent variable, for separate strata of family characteristics. The presence of buffer effects was ascertained by comparing the associations between disease variables and mobility difficulties across the strata of family characteristics, using the odds ratios and 95% confidence intervals. Living together with a partner appears to buffer the association between the presence of one chronic disease and mobility difficulties, but no such effect is present among subjects with more than one disease. Regarding specific chronic diseases, partner presence has a beneficial influence only on the association between stroke and mobility difficulties, regardless of whether the partner provides little or much support. For patients with chronic non-specific lung disease (asthma, chronic bronchitis or pulmonary emphysema), a small amount of instrumental support (help with daily chores in and around the house) received from the partner is associated with a higher risk for mobility difficulties, compared to patients who receive a large amount of instrumental support and to patients who are not living with a partner. Neither the presence of children, nor the amounts of support received from them, influences associations between specific chronic diseases and mobility difficulties. The present study provides limited evidence supporting a buffer effect of family characteristics on the association between chronic diseases and mobility. Only in elderly people with a relatively low burden of disease does family support mitigate the adverse effects of disease on physical functioning.

Disability in older adults: evidence regarding significance, etiology, and risk

OBJECTIVES

This article synthesizes and assesses current evidence about the importance of physical disability to older adults. It then considers the applications of research findings to clinical geriatrics practice.

RESULTS

Physical disability is a major adverse health outcome associated with aging. Certain subgroups of older adults, including individuals with mobility difficulty, with preclinical functional changes, and persons who are hospitalized, are at particularly high risk of becoming disabled or experiencing disability progression. The major underlying causes of physical disability are chronic diseases, including both acute events, such as hip fracture and stroke and slowly progressive diseases such as arthritis and heart disease. These diseases appear to have task-specific effects; understanding this may assist in setting treatment and prevention goals. Comorbidity, particularly certain combinations of chronic diseases, is a strong risk factor for disability in itself. Recent trials indicate that clinical interventions may be able to prevent onset or progression of disability.

CONCLUSIONS

Available evidence now suggests clinical approaches to both treatment and prevention of disability and directions for defining optimal clinical care for the future.

Self-report of difficulty in performing functional activities identifies a broad range of disability in old age

OBJECTIVE

To describe a broad range of physical disability by examining the association between a four-level measure of disability, based on self-report of difficulty in performing functional activities, and previously identified risk factors for disability.

DESIGN

Cross-sectional.

SETTING

Community-based.

PARTICIPANTS

A total of 2373 noninstitutionalized men and women aged 65 and older from the Veneto Region of Italy.

MEASUREMENTS

Odds ratios for the association of the four levels of disability (none, mild, moderate, and ADL disability) differentiated by this new measure with known risk factors for physical disability.

MAIN RESULTS

This summary measure of physical disability distinguished older persons with disability from the population typically classified as nondisabled. Twenty-one percent of study participants were identified as having Activities of Daily Living (ADL) disability (defined as self-report of difficulty in one or more ADLs), and an additional 40% had mild or moderate disability based on degree of difficulty in Instrumental Activities of Daily Living (IADLs) and physical functional activities. Hip fracture and lower extremity performance were strongly independently associated with each level of disability. The association of a range of established risk factors for disability and health care utilization measures with the levels of disability identified in our study, and the trend toward increasing odds with increasing disability, provide evidence of the construct validity of this measure.

CONCLUSIONS

Self-report of difficulty in performing functional activities identifies older persons with physical disability not ascertained by self-report of the need for help, the measure typically used to identify disability in older populations. Further studies should evaluate the potential for self-reported difficulty in functional activities to predict important disability-related outcomes.

Variable effect of comorbidity on the association of chronic cardiac failure with disability in community-dwelling older persons

The effect of cardiac failure (CF) and comorbidity on disability in older persons was studied in a cross-sectional survey. The whole population aged 65 + years (n=652; 628 eligible) living in a small town near Florence (Italy) was enrolled. Finally, 459 individuals (73.0% of eligible) underwent a multidimensional evaluation. CF was defined as a NYHA II-IV class in the presence of an obviously abnormal ECG. Disability was assessed by the 14-item WHO scale. Comorbid conditions that had a prevalence >5% and might be considered pathophysiologically unrelated to CF were also identified. The univariate association of CF with disability was analyzed. Multivariate associations were estimated as well, by taking simultaneously into account the effect of comorbid conditions that had an independent effect on disability and were considered as either confounders or effect modifiers of that association. Prevalence of CF [6.1% in the whole study population) was higher with advancing age ( >or=75 years: 8.3 versus 65-74 years: 4.5%, odds ratio, OR: 1.93, 95% confidence interval, CI: 1.02-4.18), in the presence of hypertension (OR: 2.87, 95% CI: 1.32-6.23), and among individuals who were living alone (OR: 2.44, 95% CI: 1.10-5.56). CF was associated with a higher prevalence of disability (38.5 versus 19.5% OR 2.67, 95% CI: 1.21-5.92). Comorbidity modified the association of CF with disability following two patterns: while the independent effect of CF on the prevalence of disability was similar in the absence or in the presence of chronic obstructive pulmonary disease, hearing impairment, gastrointestinal tract disease, or osteoarthritis, such effect was much larger in the presence than in the absence of visual impairment, previous stroke, or urinary incontinence. The composite pathophysiological pathways of such different interactions are still to be elucidated.

The relationship between physical performance measures and independence in instrumental activities of daily living. The FICSIT Group. Frailty and Injury: Cooperative Studies of Intervention Trials

OBJECTIVES

Understanding the relationship between physical capacity and functional status is required to design exercise interventions to maintain independent living. This study assessed the importance of physical performance in maintaining independence in Instrumental Activities of Daily Living (IADL).

DESIGN

A pre-planned meta-analysis of cross-sectional data from six sites of the Frailty and Injury: Cooperative Studies of Intervention Trials (FICSIT). Linear regression was used to estimate the relationship between physical performance and IADL.

PARTICIPANTS

2190 community-dwelling older subjects.

MEASUREMENTS

IADL was the dependent variable; gait velocity, balance function, grip strength and chair rise time were the predictor variables. Age, gender, education, falls self-efficacy, and cognitive status were covariates.

RESULTS

Gait velocity, balance function, and grip strength were independently related to IADL deficits, after correcting for covariates. The linear slopes were relatively steep. For gait, a decrease of 0.1 m s-1 was associated with 0.10 (95% Cl: 0.17, 0.04) increase in IADL deficits, which is equivalent to 1 ADL deficit in 10 subjects. The linear slopes for hand grip and balance were similar or steeper. In the sites where chair stand time was measured, an increase of 1 second in the time to rise was associated with a 0.14 (0.04, 0.24) increase in IADL deficits. The relationships found in the meta-analytic analysis were consistent across sites which enrolled subjects with widely varying levels of physical performance.

CONCLUSION

Simple measures of physical performance were strongly associated with IADL independence after correcting for many previously identified predictors of functional status. The data from this meta-analysis support testing interventions designed to improve physical performance to determine whether improved performance can maintain or improve independence in IADLs.

Decreasing disability in the 21st century: the future effects of controlling six fatal and nonfatal conditions

OBJECTIVES

This study assessed the effects of reducing fatal and nonfatal health conditions on the number of functionally limited older Americans in the coming decades.

METHODS

Data from the 1990 census and the Longitudinal Study of Aging were used to project the number of functionally limited older Americans from 2001 to 2049, assuming 1% biennial reductions in five conditions that shorten life expectancy (coronary artery disease, stroke, cancer, diabetes, and confusion) and one condition that decreases functional ability (arthritis).

RESULTS

Decreasing the prevalence of arthritis by 1% every 2 years would lead to a much greater reduction in functional limitation between 2001 and 2049 (4 million person-years) than would decreasing any of the other conditions by the same amount. Decreases in two fatal conditions (cancer and coronary artery disease) would lead to increases in functional limitation (0.9 and 0.1 million person-years, respectively).

CONCLUSIONS

Advances against common nonfatal disabling conditions would be more effective than advances against fatal conditions in blunting the large increase in the functionally limited older population anticipated in the 21st century.

The effect of medical conditions on the functional limitations of Mexican-American elderly

We examined the relationship of self-reported functional status to common medical conditions using a probability sample of 3050 noninstitutionalized Mexican-American men and women aged 65 or older and residing in the Southwestern United States (Arizona, California, Colorado, New Mexico, and Texas). All subjects were interviewed in person (n = 2,873) or by proxy (n = 177) in their homes during late 1993 and early 1994. The questionnaire obtained information on self-reported functional status and prevalence of arthritis, cancer, diabetes, stroke, heart attack, and hip fracture. The prevalence of medical conditions ranged from 4.1% for hip fracture to 40.8% for arthritis. Prevalence of impairments in seven activities of daily living ranged from 5.4% for eating to 11.7% for bathing, while 25.1% could not walk up and down stairs, and 28.9% could not walk a half mile without help. In multiple logistic regression analyses, previous diagnoses of stroke and hip fracture were most predictive of functional limitations, though all conditions examined (arthritis, cancer, diabetes, stroke, heart attack, and hip fracture) were independently associated with increased odds of impairment in some activities of daily living. In general, the odds for functional impairment associated with specific medical conditions were higher than those previously published for non-Hispanic white populations. The fact that Mexican-American elderly who live in the community and who have medical conditions, especially stroke and hip fracture, are at high risk for functional impairment probably reflects the low rate of institutionalization in this population and has implications for the provision of community-based long-term care services for Mexican-American elderly.

Cancer and comorbidity in older patients: a descriptive profile

In 1992, the National Institute on Aging (NIA) and the National Cancer Institute (NCI) initiated a study to assess the prevalence of comorbid conditions in elderly patients with cancer. Seven cancer sites were selected for the study: breast, cervix, ovary, prostate, colon, stomach, and urinary bladder. This report on approximately 7600 patients in the study sample describes the NIA/NCI approach to developing information on comorbidity in elderly patients and addresses the chronic disease burden (i.e., comorbidity) and severity for six particular conditions: arthritis, chronic obstructive pulmonary disease (COPD), diabetes, gastrointestinal problems, heart-related conditions, and hypertension. Data on comorbidity were collected by abstracting information from hospital medical records. Patients were registered in six geographic areas of the NCI Surveillance, Epidemiology, and End Results (SEER) Program. A stratified random sample of patients aged 55 to 64, 65 to 74, and 75 years or older-with the index cancers were selected. Comorbidity data were matched with data from the conventional SEER monitoring system. Analyses showed that hypertension is the most prevalent condition and is also much more common as a current management problem rather than as history for the NIA/NCI SEER Study patients. Heart conditions varied slightly in the percentage of severity reported, but percentages for all tumors remained within a range of 13 to 26% for current and past categories. A similar range was observed for arthritis, with the higher percentage seen in the current problem category. For episodic complaints (e.g., gastrointestinal problems), a medical history was more common, except for cancers that involve complaints associated with the malignancy (e.g., colon and stomach cancers and, to a lesser extent, ovarian cancer). COPD and diabetes were less prevalent. Analyses currently under way will determine the impact of a patient's comorbidity burden on the cancer care continuum of diagnosis, treatment, and survival. The broad and independent effects of chronic conditions, singly and in combination, are being examined.

Physical therapy for musculoskeletal syndromes

Judgments about the effectiveness of physical therapy in the treatment of musculoskeletal syndromes depend on the findings of the physical therapist's examination and the fit between the clinical problem and the intervention. Using a model of the process of disablement, this article outlines the theoretical basis for a physical therapist's role in remediating the impairments and functional limitations associated with musculoskeletal conditions. The research basis for the application of particular physical therapy procedures, including physical agents and mechanical modalities, to typical patient problems is presented.

Effects of aging on neuroendocrine activation in subjects and patients in the presence and absence of heart failure with left ventricular systolic dysfunction

The neuroendocrine profile and echocardiographic features of 40 patients (81 +/- 1 years, means +/- standard error) with heart failure and impaired left ventricular systolic function were compared with those of an age-matched group of healthy subjects, 20 younger patients with heart failure (aged 58 +/- 1 years) and 15 younger healthy subjects. Normal elderly subjects had a neuroendocrine profile similar to that of healthy younger subjects apart from elevated plasma norepinephrine (958 +/- 84 vs 302 +/- 118 pg/ml; p< 0.001) and atrial natriuretic peptide ( 40 +/- 6 vs 28 +/- 5 pg/ml; p<0.05). Despite a similar severity of heart failure, elderly patients had smaller ventricular dimensions (left ventricular internal dimension in diastole 51 +/- 2 vs 69 +/- 3 mm;p<0.0001 and greater impairment of ventricular compliance using Doppler indexes. Plasma norepinephrine was higher (1,191 +/- 80 vs 620 +/- 67 ppg/ml; p<0.01), and plasma atrial natriuretic peptide, plasma active renin, and angiotensin II were lower in elderly patients than in the younger patients with heart failure. As functional capacity declines with age, elderly patients may have less severe cardiac dysfunction for any given level of functional impairment, and this may account for most of the differences in neuroendocrine activity with age. Age appears to be an important determinant of plasma norepinephrine and may be a confounding factor in interpreting the prognostic significance of this hormone.

Limitations in upper-body strength associated with breast cancer: a comparison of black and white women

We examined differences in reported upper-body limitations between black and white breast cancer cases and controls aged 40 to 84 years at 3 and 12 months after diagnosis in the Detroit metropolitan area (n = 954 cases and 1000 controls at 3 months; n = 879 cases and 909 controls at 12 months). At 3 months black cases were more likely than white cases to report limitations in upper-body strength (30.4 versus 19.8%). No difference was found between black and white controls (8.0 versus 9.4%). At 12 months, the proportion of white patients with upper-body limitation returned to the same level as white controls. Black patients with limitations, however, did not return to the same level as black controls. Stage of disease was strongly associated with upper-body limitations, especially for black women. Race and stage differences in upper-body limitation could not be explained by differences in breast cancer treatment, financial adequacy, education, marital status, or comorbidity. Recommendations are made for more comprehensive studies of rehabilitation.

Function and medical comorbidity in south Texas nursing home residents: variations by ethnic group

OBJECTIVE

To evaluate differences in functional status and burdens of medical conditions in Mexican American and non-Hispanic white nursing home residents.

DESIGN AND SETTING

Cross-sectional survey of 17 nursing homes in south Texas.

PARTICIPANTS

A total of 617 older nursing home residents, of whom 366 were Mexican American and 251 were non-Hispanic white.

MEASURES

Activities of Daily Living (ADL) status abstracted from standard nurses notes and Burden of Disease abstracted from medical records.

RESULTS

Mexican American residents had greater numbers of ADL dependencies and poorer overall ADL scores than non-Hispanic white residents. This poor functioning was not explained by age, gender, or marital or educational status. The average number of medical conditions was greater, and specific conditions, such as cerebrovascular disease, recent acute infections, diabetes, hypertension, and anemia, were more common in Mexican American residents compared with non-Hispanic white residents. In models relating function with medical conditions and ethnic group, ADL scores and dependencies were significantly related to bowel and bladder incontinence, cerebrovascular disease, dementia, recent infections, and skin decubiti, but not to ethnic group.

CONCLUSION

Mexican American nursing home residents are more functionally dependent than non-Hispanic white residents. The difference in function is explained by a greater burden of medical conditions in the Mexican American residents.

Women, men, and osteoarthritis

OBJECTIVES AND METHODS

Gender differences in the prevalence and impact of arthritis are discussed, using data and analytic results from national health surveys.

RESULTS

Most cases of arthritis are osteoarthritis, an ancient disease that causes pain, physical dysfunction, and social disability, but not death. Arthritis prevalence rates rise sharply with age; it is the leading chronic condition in mid and late life. Women's rates exceed men's at all ages. Women's higher rates of disability and medical services for arthritis in the population are due mainly to higher prevalence. Among persons with arthritis, women are only a little more likely than men to be disabled or receive medical services. Persons with arthritis often have other chronic conditions as well (called comorbidity). Combining arthritis and visual problems gives a strong exacerbating push to disability.

CONCLUSIONS

Because biomedical research emphasizes pathogenesis and therapies for fatal conditions, Americans' health future will become dominated by nonfatal ones, especially arthritis. I recommend a better balance and new orientation for arthritis research that stays true to older persons' health and disability experience.

The incidence and natural history of knee osteoarthritis in the elderly. The Framingham Osteoarthritis Study

OBJECTIVE

To determine the incidence of radiographic knee osteoarthritis (OA) and symptomatic OA (symptoms plus radiographic OA), as well as the rate of progression of preexisting radiographic OA in a population-based sample of elderly persons.

METHODS

Framingham Osteoarthritis Study subjects who had knee radiographs and had answered questions about knee symptoms in 1983-1985 were reexamined in 1992-1993 (mean 8.1-year interval) using the same protocol. Subjects were defined as having new (incident) radiographic OA if they developed grade > or = 2 OA (at least definite osteophytes or definite joint space narrowing). New symptomatic OA was present if subjects developed a combination of knee symptoms and grade > or = 2 OA. Progressive OA was diagnosed when radiographs showing grade 2 disease at baseline showed grade > or = 3 disease on followup.

RESULTS

Of 1,438 participants in the original study, 387 (26.9%) died prior to followup. Of the 1,051 surviving subjects, 869 (82.7%) participated in the followup study (mean +/- SD age 70.8 +/- 5.0 at baseline). Rates of incident disease were 1.7 times higher in women than in men (95% confidence interval [CI] 1.0-2.7), and progressive disease occurred slightly more often in women (relative risk = 1.4; 95% CI 0.8-2.5) but rates did not vary by age in this sample. Among women, approximately 2% per year developed incident radiographic disease, 1% per year developed symptomatic knee OA, and about 4% per year experienced progressive knee OA.

CONCLUSION

In elderly persons, the new onset of knee OA is frequent and is more common in women than men. However, among the elderly, age may not affect new disease occurrence or progression.

Late physical and functional effects of osteoporotic fracture in women: the Rancho Bernardo Study

OBJECTIVE

To examine the associations between osteoporotic fractures and difficulty performing selected physical and functional activities.

DESIGN

Cross sectional analysis of a cohort study.

SETTING

Geographically defined cohort located in Rancho Bernardo, California.

PARTICIPANTS

Community-dwelling women aged 55 and older who participated in a study of osteoporosis between 1988-1991. Eighty percent of eligible women participated in the study.

MAIN OUTCOME MEASURES

Self-reported difficulty performing seven physical activities and four functional tasks.

RESULTS

The mean age of the 1010 women was 72.6 years. A total of 160 first minimal trauma fractures occurred between 1972 and 1991, including 62 wrist, 29 rib, 25 hip, and 23 spine fractures. The mean time since fracture was 6.7 years (range, 1 to 17 years). In multiply adjusted analyses, having experienced any osteoporotic fracture was significantly associated with a 1.7 to 3.0-fold increase in difficulty bending, lifting, reaching, walking, climbing stairs, and descending stairs. Any fracture was significantly associated with 1.9 to 6.7 times more difficulty in dressing, cooking, shopping, and performing heavy housework. Compared with the relative odds of physical limitation associated with any osteoporotic fracture, hip fractures were more strongly associated with difficulty walking (OR 3.6) and descending stairs (OR 4.1), whereas spine fractures demonstrated a stronger association with difficulty bending (OR 3.1), lifting (OR 3.4), and descending stairs (OR 4.2).

CONCLUSIONS

Among older women, remote osteoporotic fracture at any site is associated with an approximate doubling of the risk of physical limitations and an even higher risk of functional limitations. Although this cross-sectional analysis cannot secure the direction of the association, the specificity of the effect of particular fractures on discrete activities supports causality.