The biopsycho-ecological paradigm: a foundational theory for medicine

Reducing Falls in Older Women with Urinary Incontinence

Urinary incontinence is common in older women and doubles the risk of falls in this population. The association between urinary incontinence, especially urgency urinary incontinence, and falls is multifactorial and likely the result of a complex interaction between physical, mental, social, and environmental factors. As a result of this multifactorial etiology and based on existing evidence, the integration of different fall prevention strategies including strength and resistance exercises, bladder training, and home hazard reduction have the potential to decrease the risk of falls in older women with urinary incontinence. Given the prevalence of urinary incontinence and the significant morbidity associated with falls, effective interventions to reduce fall risk in older women with urinary incontinence is of high public health significance.

Non-suicidal self-injury in Chinese population: a scoping review of prevalence, method, risk factors and preventive interventions

Non-suicidal self-injury behavior (NSSI) is a serious public health concern that requires immediate attention. Despite the high prevalence of NSSI among the Chinese population, there is a significant gap in research on the comprehensive picture of this field. Therefore, a scoping review was conducted to investigate the prevalence, methods, risk factors, and preventive intervention programs related to NSSI in China. The review found that the estimated lifetime prevalence of NSSI among Chinese youth population is alarmingly high at 24.7% (N = 1,088,433). Common methods of NSSI include scratching, hitting, and biting. Additionally, the review synthesized 249 risk factors based on the biopsychosocial-ecological framework, highlighting the urgent need for intervention. However, only 12 empirical studies focus on NSSI prevention or intervention programs were included. These findings underscore the necessity for more clinical practices and larger studies to identify effective interventions and ultimately alleviate the burden of NSSI on the Chinese population.

Funding

This review was supported by Humanity and Social Science Youth foundation of Ministry of Education (22YJCZH018), Science and Technology Innovation 2030 (STI2030-Major Projects:2021ZD0200702), National Natural Science Foundation of China (81825009), and Shuimu Tsinghua Scholar. No funding agencies were involved in the data collection, data analysis, and writing of this paper.

The Bahraini food based dietary guidelines: a holistic perspective to health and wellbeing

The impact of food consumption extends well beyond the physical aspect of health to affect the mind, the society, and the environment. The biopsycho-ecological (BSE) theory recognizes the interplay between these factors and emphasizes the need for a holistic perspective to dietary recommendations. This manuscript presents a situation analysis of food consumption and diet-related diseases in Bahrain and describes the themes of the Bahraini Food based dietary guidelines (FBDG) and their alignment with the BSE constructs. Available data revealed low fruit and vegetable intake and excessive consumption of processed meat and sugary drinks in the country. These dietary habits are accompanied by a high burden of non-communicable diseases and their risk factors, anemia, and vitamin D deficiency. The Bahraini FBDG consisted of 11 context-specific themes and key messages that addressed the four dimensions of health depicted by the BSE theory, as follows: diet, physical activity, and food safety (body), physical activity, mindful eating and mental health (mind); family relations and cultural heritage (society), and food waste and environmental footprints of dietary intake (environment). The Bahraini FBDG present a model of dietary guidelines that adopted a holistic perspective to address health as they promote the role of food and dietary habits in maintaining the health of the body and that of the mind, the society, and the environment.

Informal Caregivers' Perceptions of Facilitators of Successful Weight Management for People With Spinal Cord Injury

IMPORTANCE

Informal caregivers have valuable insights that occupational therapists can use to prevent and manage problems that may arise in people with spinal cord injury (SCI) because of a lack of physical activity and poor nutrition.

OBJECTIVE

To assess caregiver-identified facilitators of weight management in people with SCI.

DESIGN

Descriptive qualitative design using semistructured interviews and thematic analysis.

SETTING

Regional SCI Care Model System and Veterans Health Administration.

PARTICIPANTS

Informal caregivers (n = 24) of people with SCI.

OUTCOMES AND MEASURES

Facilitators of successful weight management in care recipients with SCI.

RESULTS

Four themes were identified as weight management facilitators: healthy eating (subthemes: food content, self-control, self-management, and healthy preinjury lifestyle), exercise and therapy (subthemes: occupational and physical therapy, receiving assistance, and resources for exercise), accessibility, and leisure activity or activities of daily living, the latter described as a source of activity (because of required energy expenditure) to facilitate weight management for people with more severe injuries.

CONCLUSIONS AND RELEVANCE

These findings can inform the development of successful weight management plans by occupational therapists by incorporating feedback from informal caregivers. Because caregivers are involved in many of the facilitators identified, occupational therapists should communicate with the dyad about sourcing accessible places to increase physical activity and assessing in-person assistance and assistive technology needs to promote healthy eating and physical activity. Occupational therapists can use informal caregiver-identified facilitators of weight management to help prevent and manage problems for people with SCI secondary to limited activity and poor nutrition. What This Article Adds: Occupational therapy practitioners provide therapeutic intervention to people with SCI; this includes attention to weight management from the time of initial injury throughout their lives. This article is novel in the presentation of informal caregivers' perceptions about successful facilitators of weight management among people with SCI, which is important because caregivers are intimately involved in the daily activities of people with SCI and can be a liaison for occupational therapists and other health care providers about ways to facilitate healthy eating and physical activity.

ASOC Osuntokun Award Lecture 2022: Partnership for stroke prevention and treatment in Africa: Qualitative research processes and findings

BACKGROUND/OBJECTIVES

Africa has one of the highest rates of stroke and stroke deaths in the world. The burden of stroke is increasing with a 3-year mortality rate of up to 84%. Stroke disproportionately affects the young and middle-aged population contributing to morbidity and mortality affecting families, communities, health systems, and economic progress. My objectives of the 2022 Osuntokun Award Lecture at the African Stroke Organization Conference were to explore our qualitative research findings from our communities and to propose future qualitative methods for improving stroke outcomes in Africa.

METHODS

Qualitative research processes and findings related to stroke prevention, treatment/ongoing care, recovery, and knowledge and attitudes influencing ethical, legal and social implications related to stroke neuro-biobanking were explored. For each qualitative study, methods were developed by the research team including: (1) plans to implement aims and ethics review; (2) guides and detailed steps for implementation; (3) training for team; (4) pilot testing, data collection, transport, transcription, storage; (5) data analysis and manuscript development.

RESULTS

The research focused on genetics, genomics and phenomics of stroke and more recently on exploring the ethical, legal, and social implications of stroke neuro-biobanking. All included a qualitative component to obtain input and guidance from the community. As in quantitative research, questions were developed by the research team, reviewed for clarity by a small group of community members, and 1,289 community members (ages 22-85) participated in the focus groups and key informant interviews from 2014 through 2022. Answers to questions were diverse with some knowledgeable about the science of stroke prevention and treatment, but many had ideas about prevention and causes of stroke that were not supported by science and many reported using traditional healers for treatment and religious beliefs preventing brain biobanking.

CONCLUSIONS

In addition to our current qualitative research related to stroke in Africa and beyond, we must form research partnerships with communities that not only answer researchers' and community members' questions but identify and implement ways to prevent stroke and improve stroke outcomes.

Developing fluency in a language of tactile communication

Touch has been an integral part of physiotherapeutic approaches since the inception of the profession. More recently, advances in the evidence-base for exercise prescription and "active" management have brought "touch" into question. This, in part, assumes that the patient or recipient simply passively receives the input rather than being an active partner in the interaction. In this article, we propose that touch can be used as a two-way conversation between therapist and client where each is engaged in tactile communication that has the potential to raise patient awareness and improve movement-based behaviour.

Developing multivariable models for predicting headache improvement in patients with acute post-traumatic headache attributed to mild traumatic brain injury: A preliminary study

OBJECTIVES/BACKGROUND

Post-traumatic headache (PTH) is a common symptom after mild traumatic brain injury (mTBI). Although there have been several studies that have used clinical features of PTH to attempt to predict headache recovery, currently no accurate methods exist for predicting individuals' improvement from acute PTH. This study investigated the utility of clinical questionnaires for predicting (i) headache improvement at 3 and 6 months, and (ii) headache trajectories over the first 3 months.

METHODS

We conducted a clinic-based observational longitudinal study of patients with acute PTH who completed a battery of clinical questionnaires within 0-59 days post-mTBI. The battery included headache history, symptom evaluation, cognitive tests, psychological tests, and scales assessing photosensitivity, hyperacusis, insomnia, cutaneous allodynia, and substance use. Each participant completed a web-based headache diary, which was used to determine headache improvement.

RESULTS

Thirty-seven participants with acute PTH (mean age = 42.7, standard deviation [SD] = 12.0; 25 females/12 males) completed questionnaires at an average of 21.7 (SD = 13.1) days post-mTBI. The classification of headache improvement or non-improvement at 3 and 6 months achieved cross-validation area under the curve (AUC) of 0.72 (95% confidence interval [CI] 0.55 to 0.89) and 0.84 (95% CI 0.66 to 1.00). Sub-models trained using only the top five features still achieved 0.72 (95% CI 0.55 to 0.90) and 0.77 (95% CI 0.52 to 1.00) AUC. The top five contributing features were from three questionnaires: Pain Catastrophizing Scale total score and helplessness sub-domain score; Sports Concussion Assessment Tool Symptom Evaluation total score and number of symptoms; and the State-Trait Anxiety Inventory score. The functional regression model achieved R = 0.64 for modeling headache trajectory over the first 3 months.

CONCLUSION

Questionnaires completed following mTBI have good utility for predicting headache improvement at 3 and 6 months in the future as well as the evolving headache trajectory. Reducing the battery to only three questionnaires, which assess post-concussive symptom load and biopsychosocialecologic factors, was helpful to determine a reasonable prediction accuracy for headache improvement.

Randomised controlled trial of the Caring Connections intervention to reduce loneliness and perceived social isolation in persons with spinal cord injuries and disorders: study protocol

INTRODUCTION

Perceived social isolation and loneliness are understudied in individuals with spinal cord injuries and disorders (SCI/D). The few existing studies reported that they are common, yet poorly treated, in persons with SCI/D. We developed an intervention called Caring Connections (CC) aimed at reducing loneliness and perceived social isolation in persons with SCI/D. CC is a peer-based, recurrent letter writing programme designed to provide moments of positivity. We will conduct and evaluate a randomised controlled trial (RCT) to assess changes in loneliness and social isolation outcomes between the CC intervention and control conditions in community-dwelling individuals with SCI/D.

METHODS AND ANALYSIS

RCT to compare outcomes of community-dwelling individuals with SCI/D undergoing the CC intervention to an attention control group (receiving informational materials on life domains important to a good quality of life). Eligible participants include adults with chronic SCI/D who have been injured for >1 year. The primary outcome is loneliness, measured using the UCLA (University of California, Los Angeles) 3-item Loneliness Scale. Other outcomes include perceived social isolation and social support. A post-trial process evaluation will assess perceived benefits, negative impacts and satisfaction with the intervention, and areas for improvement. We will test the hypotheses of reduced loneliness and perceived social isolation in the CC intervention arm from baseline to 6 months and will also measure the magnitude of effect (difference between CC arm and attention control arm). We will use generalised linear models for repeated measures. We will assume a one-tailed, α=0.05 level of significance for comparisons. Process outcomes will be analysed using mixed methods, including frequencies for the rating items and thematic analysis for open-ended item responses.

ETHICS AND DISSEMINATION

This study has received Hines Veterans Affairs Institutional Review Board approval (#1673654). Findings will be disseminated widely through healthcare organisations, peer-reviewed publications and conferences.

TRIAL REGISTRATION NUMBER

NCT05295108.

Positive and negative ways that informal caregivers are affected by weight and weight management efforts for care recipients with spinal cord injury

PURPOSE

To understand how informal caregivers are affected by weight and weight management of care recipients with SCI.

MATERIALS AND METHODS

In-depth qualitative interviews were conducted with 24 informal caregivers of community-dwelling Veterans and civilians with SCI. Thematic analysis was conducted.

RESULTS

Three themes described how the care recipient's weight management efforts impacted the caregiver, including: (1) motivation and involvement in weight management efforts for themselves, (2) emotional well-being (positive and negative aspects), and (3) physical tasks (both ease and burden). Caregivers may experience emotional and/or physical burden by taking on extra caregiving tasks to help with care recipient's weight management. Caregivers also may experience positive impacts from the care recipient's weight management efforts, regardless of who drove the efforts, including improvement in their own motivation and involvement in weight management, enhanced emotional well-being (happiness for and with the care-recipient), and making physical caregiving tasks easier.

CONCLUSIONS

Rehabilitation providers can use these findings to educate dyads about potential impacts of weight management efforts for the care recipient, specifying areas that may cause burden but emphasizing the potential benefits for both recipient and caregiver. Integrating this education into rehabilitation practice may reduce overweight-related problems with function and declines in disability among dyads.Implications for RehabilitationInformal caregivers experience both positive and negative consequences with regard to weight management for individuals with SCI.Helping their loved one with weight management can facilitate informal caregivers' involvement in their own weight management activities.Findings may offer guidance to healthcare and rehabilitation providers as they incorporate weight management into education programs for informal caregivers of persons with SCI.Integrating this education into rehabilitation practice may reduce or delay overweight-related problems with function and declines in disability among dyads.

Development and evaluation of an educational curriculum for healthcare providers on overweight/obesity management in individuals with spinal cord injury based on diverse stakeholder engagement

BACKGROUND

Spinal cord injury (SCI) healthcare providers are aware of the harmful consequences of overweight/obesity in persons with SCI, but many are unaware of available information and lack training to guide weight management care in the SCI population.

OBJECTIVE

Describe the development and content of an educational curriculum for healthcare providers to help individuals with SCI prevent or manage overweight/obesity.

METHODS

The biopsychoecological framework guided curriculum planning, data collection, and product development. Thematic analysis of interviews conducted with individuals with SCI, informal caregivers, and SCI healthcare providers pinpointed central educational curriculum topics. SCI healthcare providers evaluated the curriculum.

RESULTS

Seven comprehensive topics were developed: 1. Scope and consequences of overweight/obesity in SCI; 2. Classifying and measuring overweight/obesity in SCI; 3. Guidelines related to weight management in SCI; 4. Identifying challenges (and solutions) to weight management in SCI; 5. Strategies for providers to facilitate weight management; 6. Understanding goals, motivators, and desired feedback for weight management; and 7. Knowing how informal caregivers are affected by weight and weight management of care recipients with SCI. High ratings (>80% strong agreement) were achieved on content, word choice, organization, relevance, and actionability. Modification needs were identified and subsequently made to layout, visual aids, and provision of tangible resources. Providers described the curriculum as a scientifically rigorous resource that addresses a knowledge gap, provides population-specific content, and is useful across interdisciplinary teams.

CONCLUSION

We developed a self-directed learning educational curriculum addressing topics most salient to stakeholders involved in overweight/obesity management of persons with SCI.

Effects of Setting on Psychedelic Experiences, Therapies, and Outcomes: A Rapid Scoping Review of the Literature

The health and well-being impacts of art and aesthetic experiences have been rigorously studied by a range of disciplines, including cognitive neuroscience, psychiatry, public health, and translational clinical research. These experiences, encompassed in the concepts of set and setting, have long been claimed to be pivotal in determining the acute and enduring effects of psychedelic experiences. Responding to the field's longstanding emphasis on the role and value of setting, a rapid scoping review was undertaken to identify the extent to which effects of setting and aesthetics on psychedelic experiences and therapies have been explicitly studied. It offers an analysis of the strengths and limitations of the extant literature and discusses evidentiary gaps as well as evidentiary opportunities for the field. The 43 included studies indicate apparent consensus regarding the importance of setting in psychedelic therapies, as well as consistent interest in theorizing about these effects. However, this consensus has yet to generate consistent, prospective, rigorous tests of setting and its complexities. As a result, the field continues to lack understanding or agreement regarding the effects of various specific elements of setting, the mechanisms by which they affect outcomes, for whom these effects occur, under what circumstances, given what conditions, and other critical factors. Further studies of setting and aesthetics in the context of psychedelic therapies are likely to not only improve these therapies and their delivery, but also inform considerations of setting and aesthetics for non-psychedelic interventions.

Short-Term Effect of Fesoterodine on Physical Function Relevant to Fall Risk in Older Women With Overactive Bladder

PURPOSE

The aim of this study was to measure the effect of treatment with fesoterodine on physical function relevant to fall risk in older women with overactive bladder.

MATERIALS AND METHODS

This was a prospective cohort study of women aged 65 years or older with overactive bladder. Urinary symptoms and physical function were measured at baseline and 8 weeks after treatment with fesoterodine. Physical activity and sedentary behavior were measured subjectively using questionnaires and objectively using an accelerometer. Physical function was measured using the Short Physical Performance Battery test.

RESULTS

We enrolled 75 women with a median age of 76 years. At baseline, bothersome urgency urinary incontinence and nocturia were reported by 55% and 81%, respectively. At baseline, participants were highly sedentary with a median of 2,118 steps daily. After treatment, urinary symptom severity and health-related quality of life subscale scores of the Overactive Bladder Questionnaire improved significantly (-22.3±24 and 17.5±19.7, respectively; P < 0.0001). The proportion of participants who self-reported a moderate-to-high level of physical activity increased from 27% to 35% after treatment (P = 0.86). However, daily steps decreased significantly (-420.2±949, P < 0.001), whereas daily sedentary time increased by 36.6±88 minutes (P < 0.001). There was no significant change in the Short Physical Performance Battery score (-0.3±2.3, P = 0.6).

CONCLUSIONS

In older women with overactive bladder, short-term treatment with fesoterodine decreased objectively measured physical activity with no significant change in physical function. Treatment with anticholinergics may need to be supplemented with other therapies to address fall risk in older women with overactive bladder.

A narrative review of biopsychosocial factors which impact overweight and obesity for individuals with acquired brain injury

Primary Objective: To discuss the biopsychosocial factors that affect being overweight or obese after acquired brain injury (ABI)Research Design: Narrative reviewMethods and Procedures: Based on the biopsychosocial model, we discuss the unique injury-specific factors that can affect bring overweight or obese among individuals with ABI including: (1) biological, (2) psychological and (3) social/ecological factors.Main Outcomes and Results: Injury-specific factors that impact being overweight or obese following ABI include endocrine dysfunction, pain, bowel and bladder incontinence, balance problems and motor impairment, medications, sleep quality and fatigue, alcohol and tobacco use, psychological disorders and symptoms, cognitive changes, social support, isolation, participation, transportation, independence, and knowledge. These factors may also compound general factors impacting weight management, making it difficult for individuals with ABI to maintain a healthy lifestyle.Conclusions: It is important to recognize the biopsychosocial factors that impact weight-loss and lifestyle change after ABI so that interventions can be tailored to meet individuals' unique needs. Empirical research is needed to better understand how biopsychosocial factors interact and impact overweight/ obesity after ABI.

Thai Older People's Willingness (Intention) to Participate in a Care Prevention, Community Group Exercise Program: An Assessment before Implementing an Intervention Trial in Chiang Mai, Northern Thailand

BACKGROUND

Sustainability of a current family-based long-term care model in Thailand has been challenged by demographic aging, and the rising burden of non-communicable diseases and age-related morbidities. In order to overcome these challenges, a community-integrated intermediary care (CIIC) service model, including functional training as one of the interventions, was introduced. To increase program uptake and adherence, it is vital to understand the facilitators and barriers for joining this group exercise. Therefore, we aimed to explore the determinants of older adults' willingness to participate in it.

METHODS

A total of 1509 participants from an intervention arm of a cluster randomized trial were interviewed with a structured questionnaire. A descriptive analysis and binary logistic regression were applied.

RESULTS

More than half of participants (51.4%) were willing to join community-based care prevention, functional training exercise program. Significant associated motivators were being of younger age, female, married, working seniors, original community residents, having (regular and irregular) exercise habits, history of a fall in the last six months, needs for walking aids and secondary caregivers.

CONCLUSION

Our findings highlighted both personal and social factors motivated old people to access health promotion activities. It might help design or implement effective programs to promote healthy aging among community-dwelling seniors in Thailand. This research is analysis of baseline results from a Community Integrated Intermediary Care project. TCTR20190412004.

The Impact of the Novel Coronavirus Disease 2019 on Therapy Service Delivery for Children with Disabilities

OBJECTIVE

To assess the impact of the novel coronavirus disease 2019 (COVID-19) pandemic on the delivery of, and parent satisfaction with, therapy services for children with disabilities in early intervention, school, and outpatient settings.

STUDY DESIGN

There were 207 parents of children with disabilities who completed a web-based survey about their child[ren]'s access to, and satisfaction with, therapy services during COVID-19. Parents also completed the Family-Provider Partnership Scale and the Telehealth Satisfaction Scale. Satisfaction was compared between families receiving therapies in school, early intervention, outpatient, and multiple settings.

RESULTS

Forty-four percent of parents reported low satisfaction with their child[ren]'s therapy services during the pandemic. Access to telehealth positively predicted overall satisfaction and satisfaction with the family-provider partnership, whereas receiving school-based therapies negatively predicted overall satisfaction and satisfaction with the family-provider partnership.

CONCLUSIONS

School-based therapies are legally mandated for eligible students, free of cost to families, integrated in the academic setting, and less burdensome on parents than other services. Thus, given the disparity in parental satisfaction regarding school-based service delivery, addressing therapy delivery in school-based settings during the duration of COVID-19 is critical for preventing increased disparities and more effectively meeting children's needs. Telehealth seems to be a promising option for continuing high-quality services during the duration of the COVID-19 pandemic and for families who face barriers in accessing services in general. Future studies are warranted with larger and more diverse samples, as well as longitudinal studies that monitor service access and parent satisfaction throughout the remainder of the pandemic.

How can neighborhood environments facilitate management of osteoarthritis: A scoping review

OBJECTIVE

The association between neighborhood environments and health outcomes has long been recognized, but the importance of environmental factors is less well examined in osteoarthritis (OA). We aimed to give an overview of the literature examining the role of neighborhood built environments in the context of OA self-management.

MATERIAL AND METHODS

A literature search between 2000 and 2019 was performed using a scoping methodology. Literature examining the influence of neighborhood built environments on health and other outcomes in people with OA, mixed or unspecified arthritis were screened by two independent reviewers. Seven domains were pre-determined based on the World Health Organization European Healthy Cities Framework. Sub-domains and themes were synthesized from the literature.

RESULTS

We included 27 studies across seven pre-determined domains, 23 sub-domains. We identified 6 key outcomes of physical activity, quality of life, community participation, resource use, psychological health, and other physical health. The majority of studies emphasized the importance of neighborhood built environment on supporting OA self-management, particularly for facilitating physical activity. The impacts on other outcomes were also considered important but were less well studied, especially access to healthy food.

CONCLUSIONS

This review highlights the potential of better using the built environment to support OA management to address many different outcomes. Understanding the impacts of different environments is the first step, and designing new and novel ways to utilize neighborhoods is needed. Implementing strategies and public policies at a neighborhood level may be a more viable way to curb further increases in the OA epidemic than addressing individual factors alone.

Stakeholder perceptions of components of a Parkinson disease care management intervention, care coordination for health promotion and activities in Parkinson's disease (CHAPS)

BACKGROUND

A recent nurse-led proactive care management intervention, Care Coordination for Health Promotion and Activities in Parkinson Disease (CHAPS), improved care quality when compared to usual care in a randomized controlled trial. Therefore, stakeholder (patient participants, nurse care managers, and Parkinson disease (PD) specialists) perceptions of key intervention components merit evaluation to inform decisions about dissemination.

METHODS

This multi-site study occurred in five southwest United States Veterans Health Administration medical centers. Stakeholders were surveyed on their perceptions of CHAPS including the CHAPS Assessment, CHAPS nurse care managers, the Siebens Domain Management Model™ (a practical clinical model), and the Siebens Health Care Notebook (Notebook) (self-care tool). Participants' electronic medical records were abstracted for perceptions of the Notebook. Statistical analysis software was used to provide summary statistics; open card sorting methodology was used to identify themes and attributes in qualitative data including usability of some components.

RESULTS

Participants, overall, highly rated their medication self-management, acknowledged some challenges with the CHAPS self-care tools, reported knowledge of PD specialist follow-up and PD red flags, and rated CHAPS nurse care managers as helpful. Nurse care manager responses indicated the CHAPS Assessment and Program highly facilitated care of their patients. Most all PD specialists would refer other patients to CHAPS. Nurse care manager and PD specialist responses indicated improved participant management of their PD. Three themes emerged in participant perceptions of the Notebook: Notebook Assets (e.g., benefits and features-liked); Deferring Notebook Review (e.g., no time to review); and Reasons for Not Using (e.g., participant preference). Shared attributes regarding the Siebens Domain Management Model and Notebook usability, reported by nurse care managers, were user-friendly, person/patient-centered, and organized. Some challenges to their use were also reported.

CONCLUSIONS

Overall, stakeholder perceptions of the proactive nurse-led CHAPS intervention indicated its value in the care of individuals with PD. Responses about the CHAPS Assessment, Siebens Domain Management Model, and Notebook self-care tool signified their usefulness. Stakeholders' constructive suggestions indicated their engagement in CHAPS. These findings support CHAPS dissemination and contribute to research in care management.

TRIAL REGISTRATION

ClinicalTrials.gov as NCT01532986 , registered on January 13, 2012.

Women's experiences of the journey to chronic widespread pain: a qualitative study

BACKGROUND

Chronic widespread pain (CWP) is a musculoskeletal disorder that affects approximately 10% of the population. It is more common in women than in men. It is important to understand how CWP develops and how it is maintained in order to prevent poor pain prognosis. Long term studies have shown that a mere part improves over time or fluctuates in their CWP condition. Female gender is one of the factors associated with persistence of CWP, suggesting men and women may experience their journey to CWP differently. The aim of the study was to explore women's experiences of the journey to CWP.

METHODS

19 women between 45 and 67 years of age who had not reported CWP in the EPIPAIN survey in 1995, but reported CWP in 2016, participated in the study. Data was collected through individual interviews, where open-ended questions were used to explore the women's experiences of their pain journey. The interviews were analyzed with a manifest qualitative content analysis.

RESULTS

The women described their journey to CWP in terms of triggering, aggravating, and consolidating factors, from which three different categories emerged. Experiencing that environmental circumstances affect the pain journey refers to factors outside the women's immediate control, which appeared as unmanageable work-related demands, lack of social support, unfavorable physical environments, and traumatic events. Experiencing that lifestyle affects the pain journey refers to events that are consciously or unconsciously carried out by the women, including different levels of physical efforts and unfavorable behaviors. Experiencing that personal attributes affect the pain journey refers to the women's characteristics in terms of an anxious state of mind and adverse biological impact.

CONCLUSIONS

The women experienced that environmental circumstances, lifestyle, and personal attributes affected their CWP. How these adversities influenced the pain journey varied among the women. These findings show that women are conscious of the complexity of the condition and can describe the broad context of their pain journey. This study confirms the complexity of pain progress and highlights the individual's awareness of this complexity, which is important to consider when introducing interventions, and when expecting compliance to interventions.

Feasibility and outcomes: Pilot Randomized Controlled Trial of a home-based integrated physical exercise and bladder-training program vs usual care for community-dwelling older women with urinary incontinence

AIMS

To assess the feasibility of a randomized controlled trial of a home-based integrated physical exercise and bladder-training program vs usual care in community-dwelling women with urinary incontinence (UI).

METHODS

We conducted a parallel arm, nonblinded, pilot randomized controlled trial of a home-based integrated physical exercise and bladder training with urge suppression and fall prevention program (ExerciseUP) vs usual care in women aged 65 and older with UI. Outcomes included feasibility (process, resources, management, and acceptability), urinary symptoms, and falls risk using self-administered questionnaires. Objective physical activity was measured using accelerometry.

RESULTS

A total of 37 of 38 (97%) eligible women were willing to participate in the study. In the ExerciseUP intervention cohort, 17 of 19 (89%) women completed all 6 weeks of intervention and follow-up, and 16 of 18 (89%) women in the usual group completed follow-up. Ten (53%) women in the ExerciseUP group achieved at least 70% adherence to exercise prescription. The improvement in UI severity scores from baseline was greater in the ExerciseUP intervention group than the usual care group (- 6.2 ± 5.8 vs - 2.4 ± 4.2, P = 0.04). Fall-risk score decreased (improved) in both groups. There were no significant between-group differences in change in physical activity or sedentary behavior.

CONCLUSIONS

We determined that it would be feasible to conduct a home-based exercise intervention in older women with UI. Our clinical outcomes were modestly favorable for the ExerciseUP intervention group.

Prescribing Physical, Occupational, and Speech Therapy Services for Children With Disabilities

Pediatric health care providers are frequently responsible for prescribing physical, occupational, and speech therapies and monitoring therapeutic progress for children with temporary or permanent disabilities in their practices. This clinical report will provide pediatricians and other pediatric health care providers with information about how best to manage the therapeutic needs of their patients in the medical home by reviewing the International Classification of Functioning, Disability and Health; describing the general goals of habilitative and rehabilitative therapies; delineating the types, locations, and benefits of therapy services; and detailing how to write a therapy prescription and include therapists in the medical home neighborhood.

Social factors and Australian farmer suicide: a qualitative study

BACKGROUND

Farmers and farm workers have been recognised as a group at high risk of suicide in Australia; however this risk is not without geographic and demographic variation. This study aims to identify and better understand the complex interplay of risk and protective factors surrounding farmer suicide, with an emphasis on social influences, so as to inform tailored and effective suicide prevention initiatives.

METHODS

Focus groups were conducted in three diverse sites across two states in Australia with men and women separately to gain perceptions about suicide risk and protective factors and attitudes towards suicide and help seeking. The three communities in each state represented areas with a suicide rate similar to, above, and below the state average. The communities were also diverse in their population, types of farming, geographic location, distance from and access to services. There were a total of 33 female and 30 male participants.

RESULTS

Qualitative analysis indicated three major interrelated social factors: (1) changing rural communities, (2) community attitudes and stigma and (3) relationship issues.

CONCLUSIONS

The biopsycho-ecological model is considered useful to better understand and address social, as well as individual and environmental factors, pertaining to farmer suicide.

Ecological Factors Predict Transition Readiness/Self-Management in Youth With Chronic Conditions

PURPOSE

Health care transition readiness or self-management among adolescents and young adults (AYA) with chronic conditions may be influenced by factors related to their surrounding environment.

METHODS

Study participants were AYA diagnosed with a chronic condition and evaluated at pediatric- and adult-focused subspecialty clinics at the University of North Carolina Hospital Systems. All participants were administered a provider-administered self-management/transition-readiness tool, the UNC TRxANSITION Scale. Geographic area and associated characteristics (ecological factors) were identified for each participant's ZIP code using the published U.S. Census data. The Level 1 model of the hierarchical linear regression used individual-level predictors of transition readiness/self-management. The Level 2 model incorporated the ecological factors.

RESULTS

We enrolled 511 AYA with different chronic conditions aged 12-31 years with the following characteristics: mean age of 20± 4 years, 45% white, 42% black, and 54% female. Participants represented 214 ZIP codes in or around North Carolina, USA. The Level 1 model showed that age, gender, and race were significant predictors of transition readiness/self-management. On adding the ecological factors in the Level 2 model, race was no longer significant. Participants from a geographic area with a greater percentage of females (β = .114, p = .005) and a higher median income (β = .126, p = .002) had greater overall transition readiness. Ecological factors also predicted subdomains of transition readiness/self-management.

CONCLUSIONS

In this cohort of adolescents and young adults with different chronic conditions, ecological disparities such as sex composition, median income, and language predict self-management/transition readiness. It is important to take ecological risk factors into consideration when preparing patients for health self-management or transition.

Development and Validation of Prognostic Indices for Recovery of Physical Functioning Following Stroke: Part 2

OBJECTIVE

To develop a prognostic index for achievement of modified independence (Functional Independence Measure grade VI) after completion of either comprehensive or consultative rehabilitation after stroke.

DESIGN

Retrospective cohort study.

SETTING

Veterans Affairs Medical Centers (VAMCs) throughout the United States.

PARTICIPANTS

Data included 5316 patients with stroke discharged from VAMCs who received rehabilitation services while hospitalized and who were physically dependent at initial assessment. The index was derived with use of 60% of the sample and validated in the remaining 40% of the sample. Points derived from the β coefficients of a multivariable logistic model were added to scores that were associated with the probability of recovery.

MAIN OUTCOME MEASURE

Recovery to modified independence or above at final rehabilitation assessment, defined as when patients no longer need physical assistance with eating; grooming; dressing the upper and lower body; toileting; sphincter management; bed to chair, toilet, and tub transfers; and walking/wheelchair use and when they require no more than supervision with bathing or climbing stairs.

RESULTS

Seven independent predictors were identified through logistic regression in the derivation sample: initial physical grade (I or II = 0 points; III = 2 points; IV = 4 points; V = 5 points), initial cognitive stage (I or II = 0 points; III = 2 points; IV = 3 points, V or VI = 4 points; VII =5 points), type of rehabilitation (consultative = 0 points; comprehensive = 4 points), age (<60 years = 3 points; 60-79 years = 2 points; ≥80 years = 0 points), time from initial to final physical grade assessment (1-2 days = 0 points; ≥3 days = 2 points), absence of urinary procedures (3 points), and absence of diabetes with complications (1 point). The following proportions of patients recovered to physical grade VI for the first, second, third, and fourth quartile scores, respectively: 0.59% (score ≤9), 3.87% (score = 9-11), 14.19% (score = 12-15), and 37.38% (score ≥16).

CONCLUSION

Functional recovery to physical grade VI can be predicted on the basis of patients' initial status after a stroke occurs and the type of rehabilitation services to be provided by using a simple scoring system.

Activity Limitation Stages empirically derived for Activities of Daily Living (ADL) and Instrumental ADL in the U.S. Adult community-dwelling Medicare population

BACKGROUND

Stages quantify severity like conventional measures but further specify the activities that people are still able to perform without difficulty.

OBJECTIVE

To develop Activity Limitation Stages for defining and monitoring groups of adult community-dwelling Medicare beneficiaries.

DESIGN

Cross-sectional.

SETTING

Community.

PARTICIPANTS

There were 14,670 respondents to the 2006 Medicare Current Beneficiary Survey.

METHODS

Stages were empirically derived for the Activities of Daily Living (ADLs) and the Instrumental Activities of Daily Living (IADLs) by profiling the distribution of performance difficulties as reported by beneficiaries or their proxies. Stage prevalence estimates were determined, and associations with demographic and health variables were examined for all community-dwelling Medicare beneficiaries.

MAIN OUTCOME MEASUREMENTS

ADL and IADL stage prevalence.

RESULTS

Stages (0-IV) define 5 groups across the separate ADL and IADL domains according to hierarchically organized profiles of retained abilities and difficulties. For example, at ADL-I, people are guaranteed to be able to eat, toilet, dress, and bathe/shower without difficulty, whereas they experience limitations getting in and out of bed or chairs and/or difficulties walking. In 2006, an estimated 6.0, 2.9, 2.2, and 0.5 million beneficiaries had mild (ADL-I), moderate (ADL-II), severe (ADL-III), and complete (ADL-IV) difficulties, respectively, with estimates for IADL stages even higher. ADL and IADL stages showed expected associations with age and health-related concepts, supporting construct validity. Stages showed the strongest associations with conditions that impair cognition.

CONCLUSIONS

Stages as aggregate measures reveal the ADLs and IADLs that people are still able to do without difficulty, along with those activities in which they report having difficulty, consequently emphasizing how groups of people with difficulties can still participate in their own lives. Over the coming decades, stages applied to populations served by vertically integrated clinical practices could facilitate large-scale planning, with the goal of maximizing personal autonomy among groups of community-dwelling people with disabilities.

"Stuck in the muck": an eco-idiom of distress from childhood respiratory diseases in an urban mangrove in Northeast Brazil

Situated in neo-democratic globalizing Northeast Brazil, this anthropological study probes the role of ecological context in framing, experiencing, and expressing human distress. Ethnographic interviews, narratives, and "contextualized semantic analysis" reveal the lived experience of childhood respiratory diseases among 22 urban mangrove dwellers. Informants speak an "eco-idiom of respiratory distress" based on a popular "eco-logic", reflecting the harsh reality of "living in dampness". "Higher-up" residents legitimize their feelings of superiority by stigmatizing "lowlanders" as taboo, diseased (with porcine cysticercosis, swine flu) "filthy pigs, stuck in the muck" (atolados na lama). Animalizing inhabitants' identities demotes them to nonpersons. Besides infections, children suffer social stigma, ostracism, and barriers for accessing care. Promoting a "favorable environment" requires reducing ecological risk, challenging class-based prejudice, and restoring human dignity.

Instrumental activities of daily living staging as a possible clinical tool for falls risk assessment in physical medicine and rehabilitation

OBJECTIVE

To determine whether instrumental activity of daily living (IADL) limitation stages can distinguish among elderly, community-dwelling persons with high likelihoods to have fallen once and more than once.

DESIGN

A cross-sectional survey.

SETTING

A nationally representative sample from the Second Longitudinal Study of Aging (LSOA II).

PARTICIPANTS

Included were 7401 community-dwelling persons 70 years of age and older.

METHODS

The association of falling once and more than once within the past 12 months and 5 stages of increasing IADL limitation were explored by using a multinomial logistic regression model that controlled for demographics, education, perceived lack of home accessibility features, and health conditions. Sample proportions were weighted to reflect the prevalence in the U.S. population of 1994.

MAIN OUTCOME MEASUREMENTS

Subject recall of fall history. There were 3 categories for this variable: no fall, falling once, and falling more than once in the past 12 months.

RESULTS

Compared with IADL stage 0, the adjusted relative risk ratio of falling once peaked in individuals at IADL stage II at 2.0 (95% confidence interval [CI], 1.5-2.6), and those at IADL stage III had a relative risk ratio of 1.8 (95% CI, 1.3-2.6). The relative risk ratio of falling more than once was 2.1 (95% CI, 1.7-2.6), 4.0 (95% CI, 3.0-5.3), 3.7 (95% CI, 2.8-5.0), and 2.7 (95% CI, 1.5-4.9) for IADL stages I, II, III, and IV, respectively, when treating IADL stage 0 as reference.

CONCLUSIONS

IADL limitation stages could represent a powerful and practical tool for screening patients in the U.S. elderly population according to fall risk. Clinical implementation and prospective testing for validation as a screening tool would be necessary.

Strengthening information capture in rehabilitation discharge summaries: an application of the Siebens Domain Management Model

OBJECTIVE

To increase relevant information capture in inpatient rehabilitation discharge summaries.

DESIGN

In July 2008, the Siebens Domain Management Model (SDMM) was incorporated into discharge summaries. This model organizes patients' health-related issues into 4 domains: I. Medical/Surgical Issues, II. Mental Status/Emotions/Coping, III. Physical Function, and IV. Living Environment (© Hilary C. Siebens MD 2005). Discharge summary content was measured through retrospective chart review.

SETTING

An inpatient rehabilitation unit affiliated with a physical medicine and rehabilitation residency program.

PARTICIPANTS

Forty cases with discharge summaries: 20 traditional reports (historic controls) and 20 SDMM reports after model introduction randomly chosen from residents' final inpatient rotation week.

METHODS

A documentation review form included 36 items that covered the 4 SDMM domains and assessed item presence in reports. The Global score and 4 Domain scores per each patient report were calculated to reflect the percentage of items present in the entire report and each domain, respectively. Descriptive statistics for these scores were generated and compared between traditional and SDMM reports by using a 2-group t-test.

MAIN OUTCOME MEASUREMENTS

Global scores and Domain scores.

RESULTS

Global scores increased from 34% to 53% of items present in traditional versus SDMM reports respectively (P < .001); Domain Scores also increased in domains I (81% to 92%, P = .047), II (9% to 47%, P < .001), III (25% to 34%, P = .062), and IV (11% to 33%, P < .001).

CONCLUSION

Traditional rehabilitation discharge summaries lacked information relevant to rehabilitation care. Information capture and total relevant report content increased significantly after SDMM integration into reports.

The role of folic acid in fetal programming of birth phenotypes and early human development: a biopsychosocial perspective

Preterm birth, low birthweight, intrauterine growth retardation and small for gestational age are birth phenotypes that significantly contribute to life-long morbidity and mortality. This review examines the epidemiologic and biologic evidence of folic acid (FA) as a potential population-based intervention to curtail some adverse birth phenotypic expressions, and by extension, their later physical and neurodevelopmental consequences. We outlined a feto-placental adaptation categorization taking into account how prenatal insults may be encoded in fetal development, the adaptive success of the feto-placental response, and subsequent expression in the health of the fetus. Although there are plausible biological pathways that can be implicated, we found that the epidemiological evidence on the role of perinatal FA nutriture and fetal programming of adverse birth phenotypes is still inconclusive. Because biologic and epidemiological considerations alone do not suffice in deciphering the utility of FA in averting adverse birth phenotypes, we proposed a biopsychosocial model that takes into account multi-layered psychosocial contexts for improving subsequent research studies in this area.

Prognosis for functional deterioration and functional improvement in late life among community-dwelling persons

OBJECTIVE

To examine how health-related, socioeconomic, and environmental factors combine to influence the onset of activity of daily living (ADL) limitations or prognosis for death or further functional deterioration or improvement among elderly people.

DESIGN

A national representative sample with 2-year follow-up.

SETTING

Community-dwelling people.

PARTICIPANTS

Included were 9447 persons (≥70 years of age) in the United States from the Second Longitudinal Study of Aging who were interviewed in 1994, 1995, or 1996.

METHODS

Self- or proxy-reported health conditions, ADLs expressed as 5 stages describing severity and pattern of limitations, and other baseline characteristics were obtained. A multinomial logistic regression model was used to predict stage transitions. Because of incomplete follow-up (17.7% of baseline sample), primary analyses were determined by multiple imputation to address potential bias associated with loss to follow-up.

MAIN OUTCOME MEASUREMENT

ADL stage transitions in 2 years (death, deteriorated, stable, and improved ADL function).

RESULTS

In the imputed-case analysis, the percentages for those who died, deteriorated, were stable, and improved were 12.6%, 32.7%, 48.4%, and 6.2%, respectively. Persons at a mild stage of ADL limitation were most likely to deteriorate further. Persons at advanced stages were most likely to die. Married people and high school graduates had a lower likelihood of deterioration. The risk of mortality and functional deterioration increased with age. Certain conditions, such as diabetes, were associated both with mortality and functional deterioration; other conditions, such as cancer, were associated with mortality only, and arthritis was associated only with functional deterioration.

CONCLUSIONS

Although overlap occurs, different clinical traits are associated with mortality, functional deterioration, and functional improvement. ADL stages might aid physical medicine and rehabilitation clinicians and researchers in developing and monitoring disability management strategies targeted to maintaining and enhancing self-care among community-dwelling older people.

Do elderly people at more severe activity of daily living limitation stages fall more?

OBJECTIVE

The aim of this study was to explore how activity of daily living (ADL) stages and the perception of unmet needs for home accessibility features associate with a history of falling.

DESIGN

Participants were from a nationally representative sample from the Second Longitudinal Survey of Aging conducted in 1994. The sample included 9250 community-dwelling persons 70 yrs or older. The associations of ADL stage and perception of unmet needs for home accessibility features with a history of falling within the past year (none, once, or multiple times) were explored after accounting for sociodemographic characteristics and comorbidities using a multinomial logistic regression model.

RESULTS

The adjusted relative risk of falling more than once peaked at 4.30 (95% confidence interval, 3.29-5.61) for persons with severe limitation (ADL-III) compared those with no limitation (ADL-0) then declined for those at complete limitation (ADL-IV). The adjusted relative risks of falling once and multiple times were 1.42 (95% confidence interval, 1.07-1.87) and 1.85 (95% confidence interval, 1.44-2.36), respectively, for those lacking home accessibility features.

CONCLUSIONS

Risk of falling appeared greatest for those whose homes lacked accessibility features and peaked at intermediate ADL limitation stages, presumably at a point when people have significant disabilities but sufficient function to remain partially active.

Home accessibility, living circumstances, stage of activity limitation, and nursing home use

OBJECTIVE

To explore the influence of physical home and social environments and disability patterns on nursing home (NH) use.

DESIGN

Longitudinal cohort study. Self- or proxy-reported perception of home environmental barriers accessibility, 5 stages expressing the severity and pattern of activities of daily living (ADLs) limitations, and other characteristics at baseline were applied to predict NH use within 2 years or prior to death through logistic regression.

SETTING

General community.

PARTICIPANTS

Population-based, community-dwelling individuals (N=7836; ≥70y) from the Second Longitudinal Study of Aging interviewed in 1994 with 2-year follow-up that was prospectively collected.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

NH use within 2 years.

RESULTS

Perceptions of home environmental barriers and living alone were both associated with approximately 40% increased odds of NH use after adjustment for other factors. Compared with those with no limitations at ADL stage 0, the odds of NH use peaked for those with severe limitations at ADL stage III (odds ratio [OR]=3.12; 95% confidence interval [CI], 2.20-4.41), then declined sharply for those with total limitations at ADL stage IV (OR=.96; 95% CI, .33-2.81). Sensitivity analyses for missing NH use showed similar results.

CONCLUSIONS

Accessibility of home environment, living circumstance, and ADL stage represent potentially modifiable targets for rehabilitation interventions for decreasing NH use in the aging U.S. population.

Staging activity limitation and participation restriction in elderly community-dwelling persons according to difficulties in self-care and domestic life functioning

OBJECTIVE

This study aimed to describe the conceptual foundation and development of an activity limitation and participation restriction staging system for community-dwelling people 70 yrs or older according to the severity and types of self-care (activities of daily living [ADLs]) and domestic life (instrumental ADLs (IADLs)) limitations experienced.

DESIGN

Data from the second Longitudinal Study of Aging (N = 9447) were used to develop IADL stages through the analyses of self- and proxy-reported difficulties in performing IADLs. An analysis of activity limitation profiles identified hierarchical thresholds of difficulty that defined each stage. IADL stages are combined with ADL stages to profile status for independent living.

RESULTS

IADL stages define five ordered thresholds of increasing activity limitations and a ``not relevant'' stage for those who normally have someone else do those activities. Approximately 42% of the population experience IADL limitations. To achieve a stage, a person must meet or exceed stage-specific thresholds of retained functioning defined for each activity. Combined ADL and IADL stages define 29 patterns of activity limitations expressing the individual's potential for participating in life situations pertinent to self-care and independent community life.

CONCLUSIONS

ADL and IADL stages can serve to distinguish between groups of people according to both severity and the types of limitations experienced during home or outpatient assessments, in population surveillance, and in research.

All-cause 1-, 5-, and 10-year mortality in elderly people according to activities of daily living stage

OBJECTIVES

To examine the independent association between five stages of activities of daily living (ADLs) and mortality after accounting for known diagnostic and sociodemographic risk factors.

DESIGN

For five stages of ADLs (0 to IV), determined according to the severity and pattern of ADL limitations, unadjusted life expectancies and adjusted associations with mortality were estimated using a Cox proportional hazards regression model.

SETTING

Community.

PARTICIPANTS

Nine thousand four hundred forty-seven participants aged 70 and older from the second Longitudinal Study of Aging.

MEASUREMENTS

One-, 5-, and 10-year survival and time to death.

RESULTS

Median life expectancy was 10.6 years for participants with no ADL limitations and 6.5, 5.1, 3.8, and 1.6 years for those at ADL stages I, II, III, and IV, respectively. The sociodemographic- and diagnostic-adjusted hazard of death at 1 year was five times as great at stage IV as at stage 0 (hazard ratio = 5.6, 95% confidence interval = 3.8-8.3). The associations between ADL stage and mortality declined over time but remained statistically significant at 5 and 10 years.

CONCLUSION

ADL stage continued to explain mortality risk after adjusting for known risk factors including advanced age, stroke, and cancer. ADL stages might aid clinical care planning and policy as a powerful prognostic indicator particularly of short-term mortality, improving on current ADL measures by profiling activity limitations of relevance to determining community support needs.

Physical activity among persons aging with mobility disabilities: shaping a research agenda

With the aging of the baby boomer population and their accompanying burden of disease, future disability rates are expected to increase. This paper summarizes the state of the evidence regarding physical activity and aging for individuals with mobility disability and proposes a healthy aging research agenda for this population. Using a previously published framework, we present evidence in order to compile research recommendations in four areas focusing on older adults with mobility disability: (1) prevalence of physical activity, (2) health benefits of physical activity, (3) correlates of physical activity participation, and, (4) promising physical activity intervention strategies. Overall, findings show a dearth of research examining physical activity health benefits, correlates (demographic, psychological, social, and built environment), and interventions among persons aging with mobility disability. Further research is warranted.

Attempts to reach the oldest and frailest: recruitment, adherence, and retention of urban elderly persons to a falls reduction exercise program

PURPOSE OF THE STUDY

To assess the recruitment, adherence, and retention of urban elderly, predominantly African Americans to a falls reduction exercise program.

DESIGN AND METHODS

The randomized controlled trial was designed as an intervention development pilot study. The goal was to develop a culturally sensitive intervention for elderly persons who suffered a fall and visited an emergency department (ED). Participants were taught exercises during 4 on-site group classes and encouraged to continue exercising at home for 12 weeks and attend additional on-site monthly classes. The protocol included a specifically designed intervention for increasing retention through trained community interventionists drawn from the participants' neighborhoods.

RESULTS

The screening of 1,521 ED records after falling yielded the recruitment of 204 patients aged 65 years and older. Half were randomized into the falls prevention program. Of the 102 people in the intervention group, 92 completed the final 6-month assessment, 68 attended all on-site sessions, but only 1 reported exercising at home all 12 weeks. Those who lived alone were more likely (p = .03) and those with symptoms of depression were less likely (p = .05) to attend all on-site exercise classes. The final recruitment rate was estimated as 31.8%. The final retention rates were 90.2% and 87.3% for the intervention and control groups, respectively.

IMPLICATIONS

Recruitment of frail elderly African American patients is resource intensive. Adherence to the on-site exercise classes was better than to the home-based component of the program. These findings have implications for the design of future community-based exercise programs and trials.

Understanding the linkages between perceived causative impairment and activity limitations among older people living in the community: a population-based assessment

OBJECTIVE

: The aim of this study was to better understand the linkages between impairment and activity limitation among groups of elderly community-living persons.

DESIGN

: This study used a United States population-based complex survey with weights used to make accurate population prevalence estimates from the 1994 National Health Interview Survey on Disability. Included were 2429 persons 70 yrs or older with one or more activity of daily living or instrumental activity of daily living-only activity limitations. Limitations were addressed according to the impairment(s) perceived to be causing them.

RESULTS

: Musculoskeletal impairments accounted for more than one-third of all perceived causes. The odds of having any activity of daily living limitations for persons whose limitations were attributed to musculoskeletal impairments and to brain or behavioral impairments were 2.12 times (95% confidence interval, 1.63-2.76) and 3.00 times (95% confidence interval, 2.23-4.03) the odds for the reference group of cardiopulmonary and hematology impairment.

CONCLUSIONS

: Although musculoskeletal impairments were the most common cause of activity limitation, impairments associated with brain or behavioral disturbance were perceived as most disabling.

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

OBJECTIVE

To examine the cross-sectional associations between activity of daily living (ADL) limitation stage and specific physical and mental conditions, global perceived health, and unmet needs for home accessibility features of community-dwelling adults aged 70 and older.

DESIGN

Cross-sectional.

SETTING

Community.

PARTICIPANTS

Nine thousand four hundred forty-seven community-dwelling persons interviewed through the Second Longitudinal Study of Aging (LSOA II).

MEASUREMENTS

Six ADLs organized into five stages ranging from no difficulty (0) to unable (IV).

RESULTS

ADL stage showed strong ordered associations with perceived health, dementia severe enough to require proxy use, and history of stroke. For example, the relative risks (RRs) defined as risk of being at Stages I, II, III, or IV divided by risk of being at Stage 0 for those with dementia ranged from 3.2 (95% confidence interval (CI)=2.4-4.4) to 41.9 (95% CI=19.6-89.6) times the RRs for those without dementia. The RR ratios (RRR) comparing respondents who perceived unmet need for accessibility features in the home to those without these perceptions peaked at Stage III (RRR=17.8, 95% CI=13.0-24.5) and then declined at Stage IV. All models were adjusted for age, sex, and race.

CONCLUSIONS

ADL stages showed clinically logical associations with other health-related concepts, supporting external validity. Findings suggest that specificity of chronic conditions will be important in developing strategies for disability reduction. People with partial rather than complete ADL limitation appeared most vulnerable to unmet needs for home accessibility features.