Cognitive and Physical Demands of Activities of Daily Living in Older Adults: Validation of Expert Panel Ratings

Disparities in First Instrumental Activity of Daily Living Difficulty between Black and White Older Adults: Findings from the Advanced Cognitive Training in Independent and Vital Elderly Study

Objectives: Few studies have examined differences in age of onset of first self-reported instrumental activities of daily living difficulty, much less differences by race. Our objective was to determine whether there are differences in the first reported difficulty with IADLs between Black and white older adults. Methods: We analyzed data from N = 1168 participants in the Advanced Cognitive Training in Independent and Vital Elderly (ACTIVE) study. A multiple group discrete-time multiple-event process survival mixture (MEPSUM) model was used to estimate the hazard of incident IADL difficulty in seven IADL task groups. Results: No statistically significant differences were identified in the first reported IADL task group difficulty between Black and white older adults. Discussion: Our findings indicate similar patterns of early IADL difficulty in Black and white older adults, suggesting that previously reported racial disparities in ability to perform IADLs may be attributable to differences in absolute risk, not timing.

Lifestyle Factors, Cognitive Functioning, and Functional Capacity in Older Adults

Research suggests that clinical management of cognitive impairment can occur through interventions targeting lifestyle factors, such as physical exercise and sleep quality. The present study examined the associations among lifestyle factors (exercise and sleep quality), cognition, and functional capacity in older adults (ages 56-94) who completed an outpatient neuropsychological evaluation (N = 356). Exercise habits and sleep quality were accessed using a self-report questionnaire and a clinical interview. Cognitive functioning was assessed using the Dementia Rating Scale-2 (DRS-2). Functional capacity was measured by the Texas Functional Living Scale (TFLS). Results indicated that physical exercise and sleep quality were positively associated with better cognitive functioning and functional capacity. Further research is needed to elucidate the relationship between lifestyle factors, cognition, and functional capacity in older adults.

Apathy, Cognitive Impairment, and Social Support Contribute to Participation in Cognitively Demanding Activities Poststroke

Objective

To understand the extent to which apathy, cognition, and social support predict participation in activities with cognitive demands.

Design

Prospective, quantitative correlational, cross-sectional study. Setting. Outpatient treatment centers and community stroke support groups located in St. Louis, MO, and Boston, MA. Participants. 81 community-dwelling individuals ≥ 6-month poststroke with and without aphasia. Measures. Participants completed the Activity Card Sort (ACS), Apathy Evaluation Scale (AES), Medical Outcomes Study Social Support Survey (MOS-SSS), and Delis-Kaplan Executive Function System (DKEFS) Design Fluency and Trail-Making subtests.

Results

Cognitive deficits limit participation in activities with high cognitive demands. Apathy and positive social interaction influence participation, regardless of high or low cognitive demands. Poststroke aphasia did not impact return to participation in activities with high and low cognitive demands. Conclusions and Relevance. Cognitive deficits seen poststroke contribute to participation only for activities with high cognitive demands. Apathy has a significant and negative influence on participation overall. Social support is a modifiable contextual factor that can facilitate participation. Poststroke apathy can be detrimental to participation but is not well recognized. The availability of companionship from others to enjoy time with can facilitate participation.

Activity Engagement and Cognitive Performance Amongst Older Adults

Research supporting cognitive reserve theory suggests that engaging in a variety of cognitive, social, and physical activities may serve as protective factors against age-related changes in mental functioning, especially if the activities are cognitively engaging. Individuals who participate in a variety of cognitive activities have been found to be more likely to maintain a higher level of cognitive functioning and be less likely to develop dementia. In this study, we explore the relationship between engaging in a variety of activities and cognitive performance amongst 206 healthy older adults between the ages of 65–85. Age and years of education were found to be the most significant predictors of a global composite representing cognitive performance, consistent with previous work linking these variables to age-related changes in cognition and the cognitive reserve. We interpret these results to suggest that age and education are better predictors of global cognitive performance in older adults than self-reported activity engagement.

Incident Instrumental Activities of Daily Living Difficulty in Older Adults: Which Comes First? Findings From the Advanced Cognitive Training for Independent and Vital Elderly Study

Introduction: Instrumental activities of daily living (IADLs) are complex daily tasks important for independent living. Many older adults experience difficulty with IADLs as their physical and/or cognitive function begins to decline. However, it is unknown in what order IADLs become difficult. Methods: Participants from the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) study who were free of IADL difficulty at baseline (N = 1,277) were followed up to 10 years until first reported IADL difficulty. A total of 19 IADL tasks were grouped into seven task categories. A discrete-time multiple-event process survival mixture model (MEPSUM) was used to generate hazard estimates of incident IADL difficulty in seven groups from ages 65 to 80. Hazard estimates were compared in the three intervention groups (memory, inductive reasoning, and speed of information processing) vs. the no-contact control group. Results: A total of 887 (69.5%) participants reported incident difficulty in at least one IADL task category. Compared to individuals who remained free of IADL difficulty, those who reported incident difficulty were more likely to be older, female, and have lower Short Form 36 general health scores. The IADL task categories to first become difficult were housework, managing health care, and phone use. There were no differences by intervention group in the hazard estimates of incident IADL difficulty. Conclusion: Managing health care and phone use are more cognitively demanding IADLs, and individuals who experience difficulty in these tasks first may be more likely to experience cognitive decline. Recognizing early difficulty in managing health care may allow for implementation of compensation strategies to minimize unintentional medication misuse, increased adverse medical events, and unnecessary hospitalization. Training of a specific cognitive domain may not influence ordering of IADL difficulty because IADL tasks require proficiency in, and integration of, multiple cognitive domains.

Independent Older Adult's IADL and Executive Function According to Cognitive Performance

Participation in Instrumental Activities of Daily Living (IADL) is essential in occupational therapy aiming to improve the life situation of elderly. Effective executive function (EF) is important to successful functioning in IADL. The purpose of this study was to examine EF and IADL performance differences according to cognitive levels as measured by the Montreal Cognitive Assessment (MoCA), age, and gender. In all, 80 elderly (49% female; age M = 73.4) were assessed at home, with Weekly Calendar Planning Activity (WCPA-10), IADL scale, and MoCA as a cognitive screening tool for dividing into normal cognitive (NC) level and mild cognitive impairment (MCI). The comparison between the MoCA groups on the WCPA-10 and IADL shows significant differences between the groups; gender and age differed only in IADL. IADL and WCPA-10 performance among independent elderly relates to their cognitive level. We suggest that intervention that will focus on EF may assist in improving performance and maintaining participation in occupation.

Can deficits in functional capacity and practical judgment indicate cognitive impairment in older adults?

Neuropsychological literature has demonstrated a significant relationship between cognitive decline and functional capacity, but the directionality of this relationship is still not well understood. Further, the construct of practical judgment has been linked to both cognitive impairment and functional capacity, but these associations are still under-researched. Moreover, few studies to date have examined the relationships among all three constructs utilizing performance-based, ecologically valid and psychometrically sound measures. The present study aimed to address this gap in published literature and investigated whether a practical judgment and functional capacity can help differentiate individuals with cognitive dysfunction from those without. Participants were 270 community-dwelling individuals aged 56-95 years referred for neuropsychological evaluation in an outpatient setting. Bivariate correlations revealed moderate to strong relationships among the three studied variables. Additionally, logistic regression analysis indicated that ability to make sound practical judgments and ability to perform instrumental activities of daily living (IADL) can be used as indicators of cognitive impairment. The clinical implications of these findings are discussed.

Supporting construct validity of the Evaluation of Daily Activity Questionnaire using Linear Logistic Test Models

PURPOSE

Construct validity is commonly assessed by applying statistical methods to data. However, purely empirical methods cannot explain what happens between the attribute and the instrument scores, which is the core of construct validity. Linear Logistic Test Models (LLTMs) can provide such explanation by decomposing item difficulties into a weighted sum of theoretical item properties. In this study, we aim to support construct validity of the Evaluation of Daily Activity Questionnaire (EDAQ) by using item properties accounting for item difficulties.

METHODS

Dichotomized responses to the EDAQ were analyzed with (1) the Rasch model (to estimate item difficulties), and (2) LLTMs (to predict item difficulties). Seven properties of the items were identified and rated in ordinal scales by 39 Occupational Therapists worldwide. Aggregated metric estimates-the weights used to predict item difficulties in LLTMs-were derived from the ratings using seven cumulative link mixed models. Estimated and predicted item difficulties were compared.

RESULTS

The Rasch model showed acceptable fit and unidimensionality for a sample of 42 locally independent EDAQ items. The LLTM plus error showed significantly better fit than the LLTM. In the former, three of the seven properties were not significant, and the corresponding model including only the significant properties was used to predict item difficulties; they explained 77.5% of the variance in estimated item difficulties.

CONCLUSION

A satisfactory theoretical explanation of what makes an activity of daily living task more difficult than another has been provided by a LLTM plus error model, therefore supporting construct validity of the EDAQ.

Evaluation of Changes in Functional Status in the Year After Aortic Valve Replacement

IMPORTANCE

Functional status is a patient-centered outcome that is important for a meaningful gain in health-related quality of life after aortic valve replacement.

OBJECTIVE

To determine functional status trajectories in the year after transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR).

DESIGN, SETTING, AND PARTICIPANTS

A prospective cohort study with a 12-month follow-up was conducted at a single academic center in 246 patients undergoing TAVR or SAVR for severe aortic stenosis. The study was conducted between February 1, 2014, and June 30, 2017; data analysis was performed from December 27, 2017, to May 7, 2018.

EXPOSURES

Preoperative comprehensive geriatric assessment was performed and a deficit-accumulation frailty index (CGA-FI) (range, 0-1; higher values indicate greater frailty) was calculated.

MAIN OUTCOMES AND MEASURES

Telephone interviews were conducted to assess self-reported ability to perform 22 activities and physical tasks at 1, 3, 6, 9, and 12 months after the procedure.

RESULTS

Of the 246 patients included in the study, 143 underwent TAVR (74 [51.7%] women; mean [SD] age, 84.2 [5.9] years), and 103 underwent SAVR (46 [44.7%] women; age, 78.1 [5.3] years). Five trajectories were identified based on functional status at baseline and during the follow-up: from excellent at baseline to improvement at follow-up (excellent baseline-improvement), good (high baseline-full recovery), fair (moderate baseline-minimal decline), poor (low baseline-moderate decline), and very poor (low baseline-large decline). After TAVR, the most common trajectory was fair (54 [37.8%]), followed by good (33 [23.1%]), poor (21 [14.7%]), excellent (20 [14.0%]), and very poor (12 [8.4%]) trajectories. After SAVR, the most common trajectory was good (39 [37.9%]), followed by excellent (38 [36.9%]), fair (20 [19.4%]), poor (3 [2.9%]), and very poor (1 [1.0%]) trajectories. Preoperative frailty level was associated with lower probability of functional improvement and greater probability of functional decline. After TAVR, patients with CGA-FI level of 0.20 or lower had excellent (3 [50.0%]) or good (3 [50.0%]) trajectories, whereas most patients with CGA-FI level of 0.51 or higher had poor (10 [45.5%]) or very poor (5 [22.7%]) trajectories. After SAVR, most patients with CGA-FI level of 0.20 or lower had excellent (24 [58.5%]) or good (15 [36.6%]) trajectories compared with a fair trajectory (5 [71.4%]) in those with CGA-FI levels of 0.41 to 0.50. Postoperative delirium and major complications were associated with functional decline after TAVR (delirium present vs absent: 14 [50.0%] vs 11 [13.4%]; complications present vs absent: 14 [51.9%] vs 19 [16.4%]) or lack of improvement after SAVR (delirium present vs absent: 27 [69.2%] vs 31 [81.6%]; complications present vs absent: 10 [62.5%] vs 69 [79.3%]).

CONCLUSIONS AND RELEVANCE

The findings suggest that functional decline or lack of improvement is common in older adults with severe frailty undergoing TAVR or SAVR. Although this nonrandomized study does not allow comparison of the effectiveness between TAVR and SAVR, anticipated functional trajectories may inform patient-centered decision making and perioperative care to optimize functional outcomes.

A sequence-to-sequence model-based deep learning approach for recognizing activity of daily living for senior care

Ensuring the health and safety of independent-living senior citizens is a growing societal concern. Researchers have developed sensor based systems to monitor senior citizens' Activity of Daily Living (ADL), a set of daily activities that can indicate their self-caring ability. However, most ADL monitoring systems are designed for one specific sensor modality, resulting in less generalizable models that is not flexible to account variations in real-life monitoring settings. Current classic machine learning and deep learning methods do not provide a generalizable solution to recognize complex ADLs for different sensor settings. This study proposes a novel Sequence-to-Sequence model based deep-learning framework to recognize complex ADLs leveraging an activity state representation. The proposed activity state representation integrated motion and environment sensor data without labor-intense feature engineering. We evaluated our proposed framework against several state-of-the-art machine learning and deep learning benchmarks. Overall, our approach outperformed baselines in most performance metrics, accurately recognized complex ADLs from different types of sensor input. This framework can generalize to different sensor settings and provide a viable approach to understand senior citizen's daily activity patterns with smart home health monitoring systems.

Self-perceived Difficulties in Everyday Function Precede Cognitive Decline among Older Adults in the ACTIVE Study

OBJECTIVES

Careful characterization of how functional decline co-evolves with cognitive decline in older adults has yet to be well described. Most models of neurodegenerative disease postulate that cognitive decline predates and potentially leads to declines in everyday functional abilities; however, there is mounting evidence that subtle decline in instrumental activities of daily living (IADLs) may be detectable in older individuals who are still cognitively normal.

METHODS

The present study examines how the relationship between change in cognition and change in IADLs are best characterized among older adults who participated in the ACTIVE trial. Neuropsychological and IADL data were analyzed for 2802 older adults who were cognitively normal at study baseline and followed for up to 10 years.

RESULTS

Findings demonstrate that subtle, self-perceived difficulties in performing IADLs preceded and predicted subsequent declines on cognitive tests of memory, reasoning, and speed of processing.

CONCLUSIONS

Findings are consistent with a growing body of literature suggesting that subjective changes in everyday abilities can be associated with more precipitous decline on objective cognitive measures and the development of mild cognitive impairment and dementia. (JINS, 2018, 24, 104-112).

Frailty and Subsequent Disability and Mortality among Patients with Critical Illness

RATIONALE

The prevalence of frailty (diminished physiologic reserve) and its effect on outcomes for those aged 18 years and older with critical illness is unclear.

OBJECTIVES

We hypothesized greater frailty would be associated with subsequent mortality, disability, and cognitive impairment, regardless of age.

METHODS

At enrollment, we measured frailty using the Clinical Frailty Scale (range, 1 [very fit] to 7 [severely frail]). At 3 and 12 months post-discharge, we assessed vital status, instrumental activities of daily living, basic activities of daily living, and cognition. We used multivariable regression to analyze associations between Clinical Frailty Scale scores and outcomes, adjusting for age, sex, education, comorbidities, baseline disability, baseline cognition, severity of illness, delirium, coma, sepsis, mechanical ventilation, and sedatives/opiates.

MEASUREMENTS AND MAIN RESULTS

We enrolled 1,040 patients who were a median (interquartile range) of 62 (53-72) years old and who had a median Clinical Frailty Scale score of 3 (3-5). Half of those with clinical frailty (i.e., Clinical Frailty Scale score ≥5) were younger than 65 years old. Greater Clinical Frailty Scale scores were independently associated with greater mortality (P = 0.01 at 3 mo and P < 0.001 at 12 mo) and with greater odds of disability in instrumental activities of daily living (P = 0.04 at 3 mo and P = 0.002 at 12 mo). Clinical Frailty Scale scores were not associated with disability in basic activities of daily living or with cognition.

CONCLUSIONS

Frailty is common in critically ill adults aged 18 years and older and is independently associated with increased mortality and greater disability. Future studies should explore routine screening for clinical frailty in critically ill patients of all ages. Interventions to reduce mortality and disability among patients with heightened vulnerability should be developed and tested. Clinical trial registered with www.clinicaltrials.gov (NCT 00392795 and NCT 00400062).

Assessing the Functional Status of Older Cancer Patients in an Ambulatory Care Visit

Functional status assessment is a useful and essential component of the complete history and physical exam of the older patient diagnosed with cancer. Functional status is the ability to conduct activities that are necessary for independence and more executive activities, such as money management, cooking, and transportation. Assessment of functional status creates a portal into interpreting the health of in older persons. Understanding limitations and physical abilities can help in developing cancer treatment strategies, patient/family teaching needs, and in-home services that enhance patient/family care. This article will review the benefits of functional assessment, instruments that can be used during an ambulatory care visit, and interventions that can address potential limitations.