Underestimation of disability in community-living older persons

Relationship Between Distressing Symptoms and Changes in Disability After Major Surgery Among Community-living Older Persons

OBJECTIVES

To evaluate the relationship between distressing symptoms and changes in disability after major surgery and to determine whether this relationship differs according to the timing of surgery (nonelective vs elective), sex, multimorbidity, and socioeconomic disadvantage.

BACKGROUND

Major surgery is a common and serious health event that has pronounced deleterious effects on both distressing symptoms and functional outcomes in older persons.

METHODS

From a cohort of 754 community-living persons, aged 70 or older, 392 admissions for major surgery were identified from 283 participants who were discharged from the hospital. The occurrence of 15 distressing symptoms and disability in 13 activities were assessed monthly for up to 6 months after major surgery.

RESULTS

Over the 6-month follow-up period, each unit increase in the number of distressing symptoms was associated with a 6.4% increase in the number of disabilities [adjusted rate ratio (RR): 1.064; 95% CI: 1.053, 1.074]. The corresponding increases were 4.0% (adjusted RR: 1.040; 95% CI: 1.030, 1.050) and 8.3% (adjusted RR: 1.083; 95% CI: 1.066, 1.101) for nonelective and elective surgeries. Based on exposure to multiple (ie, 2 or more) distressing symptoms, the adjusted RRs (95% CI) were 1.43 (1.35, 1.50), 1.24 (1.17, 1.31), and 1.61 (1.48, 1.75) for all, nonelective, and elective surgeries. Statistically significant associations were observed for each of the other subgroups with the exception of individual-level socioeconomic disadvantage for the number of distressing symptoms.

CONCLUSIONS

Distressing symptoms are independently associated with worsening disability, providing a potential target for improving functional outcomes after major surgery.

Changes in Restricting Symptoms after Critical Illness among Community-Living Older Adults

Rationale: Survivors of critical illness have multiple symptoms, but how restricting symptoms change after critical illness and whether these changes differ among vulnerable subgroups is unknown. Objectives: To evaluate changes in restricting symptoms over the six months after critical illness among older adults and to determine whether these changes differ by sex, multimorbidity, and individual- and neighborhood-level socioeconomic disadvantage. Methods: From a prospective longitudinal study of 754 community-living adults ⩾70 years old interviewed monthly (1998-2018), we identified 233 admissions from 193 participants to the ICU. The occurrence of 15 restricting symptoms, defined as those leading to restricted activity, were ascertained during interviews in the month before ICU admission (baseline) and each of the six months after hospital discharge. Measurements and Main Results: The occurrence and number of restricting symptoms increased more than threefold in the six months after a critical illness hospitalization (adjusted rate ratio [95% confidence interval], 3.1 [2.1-4.6] and 3.3 [2.1-5.3], respectively), relative to baseline. These increases were largest in the first month after hospitalization (adjusted rate ratio [95% confidence interval], 5.3 [3.8-7.3] and 5.4 [3.9-7.5], respectively] before declining and becoming nonsignificant in the third month. Increases in restricting symptoms did not differ significantly by sex, multimorbidity, or individual- or neighborhood-level socioeconomic disadvantage. Conclusions: Restricting symptoms increase substantially after a critical illness before returning to baseline three months after hospital discharge. Our findings highlight the need to incorporate symptom management into post-ICU care and for further investigation into whether addressing restricting symptoms can improve quality of life and functional recovery among older ICU survivors.

Distressing symptoms after major surgery among community-living older persons

BACKGROUND

Relatively little is known about how distressing symptoms change among older persons in the setting of major surgery. Our objective was to evaluate changes in distressing symptoms after major surgery and determine whether these changes differ according to the timing of surgery (nonelective vs. elective), sex, multimorbidity, and socioeconomic disadvantage.

METHODS

From a prospective longitudinal study of 754 nondisabled community-living persons, 70 years of age or older, 368 admissions for major surgery were identified from 274 participants who were discharged from the hospital from March 1998 to December 2017. The occurrence of 15 distressing symptoms was ascertained in the month before and 6 months after major surgery. Multimorbidity was defined as more than two chronic conditions. Socioeconomic disadvantage was assessed at the individual level, based on Medicaid eligibility, and neighborhood level, based on an area deprivation index (ADI) score above the 80th state percentile.

RESULTS

In the month before major surgery, the occurrence and mean number of distressing symptoms were 19.6% and 0.75, respectively. In multivariable analyses, the rate ratios, denoting proportional increases in the 6 months after major surgery relative to presurgery values, were 2.56 (95% confidence interval [CI], 1.91-3.44) and 2.90 (95% CI, 2.01-4.18) for the occurrence and number of distressing symptoms, respectively. The corresponding values were 3.54 (95% CI, 2.06-6.08) and 4.51 for nonelective surgery (95% CI, 2.32-8.76) and 2.12 (95% CI, 1.53-2.92) and 2.20 (95% CI, 1.48-3.29) for elective surgery; p-values for interaction were 0.030 and 0.009. None of the other subgroup differences were statistically significant, although men had a greater proportional increase in the occurrence and number of distressing symptoms than women.

CONCLUSIONS

Among community-living older persons, the burden of distressing symptoms increases substantially after major surgery, especially in those having nonelective procedures. Reducing symptom burden has the potential to improve quality of life and enhance functional outcomes after major surgery.

Strengthening problem-solving skills through occupational therapy to improve older adults' occupational performance - A systematic review

Background: Evidence supports the role of occupational therapy (OT) for older adults, and therapeutic use of problem solving may provide a way to improve older adult's occupational performance.Aim: To assess the effectiveness and describe the contents of OT interventions aimed at improving older adults' occupational performance by strengthening their problem-solving skills.Material and Methods: This systematic review followed the phases recommended by the Cochrane Collaboration. The following databases were searched for clinical trials on OT for populations 65+ years: CINAHL, EMBASE, MEDLINE and PsycINFO. The Cochrane risk-of-bias tool (RoB-2) and the GRADE approach were used to assess the quality of the evidence. Results were presented in tables and by narrative syntheses.Results: Five studies were included comprising a total of 685 participants. In four studies, OT with a problem-solving approach outperformed control conditions post intervention. The interventions involved problem identification, analysis, strategy development and implementation. Although no serious risk of bias was detected in the individual studies, the quality of evidence was deemed low due to inconsistent and imprecise results.Conclusions: Low-quality evidence suggests that strengthening older adults' problem-solving skills may improve their occupational performance.Significance: Further investigation is required before firm practice recommendations can be prepared.

Patterns of change and factors associated with IADL function decline in community-dwelling older adults with arthritis

Arthritis is a major cause of functional decline, which affects the quality of life (QoL) of older adults. This study analyzed instrumental activities of daily living (IADL) patterns in older adults with arthritis and the risk factors of functional decline. Data from the Korean Longitudinal Study of Aging (KLoSA), in which the participants were community-dwelling older adults aged ≥ 65 years and conducted every two years, were used to examine patterns in IADL performance between 2006 and 2016. The participants comprised 1,822 older adults, divided into an arthritis group and a non-arthritis group. A Generalized Estimating Equations (GEE) model and Kaplan–Meier analysis was used for the data analysis. The arthritis groups showed a statistically significant decrease in IADL function in 2012 (β = 1.283, p = 0.026), 2014 (β = 1.323, p = 0.028), and 2016 (β = 1.484, p = 0.014). The GEE model identified psychological conditions (depressive symptoms, cognitive function) and number of chronic diseases in the arthritis group as risk factors for increased IADL dependence. Healthcare providers should develop strategies to manage long-term functional decline, including programs to manage and prevent chronic diseases, cognitive function decline, and keep depressive symptoms under control, beginning within six years of arthritis diagnosis.

Trajectories of physical capacity among community-dwelling older adults in the United States

OBJECTIVE

Although the prognostic value of physical capacity is well-established, less is known about longitudinal patterns of physical capacity among community-dwelling older adults. We sought to describe long-term trajectories of physical capacity in a nationally representative sample of Medicare beneficiaries.

DESIGN

Cohort study SETTING AND PARTICIPANTS: Annually collected data on 6,783 community-dwelling participants in the National Health and Aging Trends Study from 2011 to 2016 were analyzed.

METHODS

Performance-based physical capacity was measured using the Short Physical Performance Battery [(SPPB) range: 0-12, higher is better]. Self-reported physical capacity was measured using six pairs of activities with composite scores from 0 to 12 (higher is better). We then used group-based trajectory modeling to identify longitudinal patterns of each physical capacity measure over 6 years. Associations of baseline characteristics with trajectories were examined using multinomial logistic regression.

RESULTS

The cohort was 57% female, 68% white, and 58% were ≥75 years. Six distinct trajectories of SPPB scores were identified. Two "high" groups (n = 2192, 43%) maintained high average SPPB scores. Two "moderate decline" groups (n = 1459, 29%) had a mid-range SPPB score at baseline and demonstrated gradual decline. A "low decline" group (n = 811, 16%) started with a low SPPB score and experienced a greater decline. A "very low" group (n = 590, 12%) had very low SPPB scores in all years. Six trajectories for self-reported physical capacity were also identified. Older age, worse health, lower income and education, and being Black or Hispanic were associated with lower and declining physical capacity.

Geriatric vulnerability and the burden of disability after major surgery

BACKGROUND

Strong epidemiologic evidence linking indicators of geriatric vulnerability to long-term functional outcomes after major surgery is lacking. The objective of this study was to evaluate the association between geriatric vulnerability and the burden of disability after hospital discharge for major surgery.

METHODS

From a prospective longitudinal study of 754 nondisabled community-living persons, aged 70 years or older, 327 admissions for major surgery were identified from 247 participants who were discharged from the hospital from March 1997 to December 2017. The indicators of geriatric vulnerability were ascertained immediately prior to the major surgery or during the prior comprehensive assessment, which was completed every 18 months. Disability in 13 essential, instrumental and mobility activities was assessed each month.

RESULTS

The burden of disability over the 6 months after major surgery was considerably greater for non-elective than elective surgery. In multivariable analysis, 10 factors were independently associated with disability burden: age 85 years or older, female sex, Black race or Hispanic ethnicity, neighborhood disadvantage, multimorbidity, frailty, one or more disabilities, low functional self-efficacy, smoking, and obesity. The burden of disability increased with each additional vulnerability factor, with mean values (credible intervals) increasing from 1.6 (1.4-1.9) disabilities for 0-1 vulnerability factors to 6.6 (6.0-7.2) disabilities for 7 or more vulnerability factors. The corresponding values were 1.2 (0.9-1.5) and 5.9 (5.0-6.7) disabilities for elective surgery and 2.6 (2.1-3.1) and 8.2 (7.3-9.2) disabilities for non-elective surgery.

CONCLUSIONS

The burden of disability after hospital discharge for major surgery increases progressively as the number of geriatric vulnerability factors increases. These factors can be used to identify older persons who are particularly susceptible to poor functional outcomes after major surgery, and a subset may be amenable to intervention, including frailty, low functional self-efficacy, smoking, and obesity.

Association Between Neighborhood Disadvantage and Functional Well-being in Community-Living Older Persons

IMPORTANCE

Neighborhood disadvantage is a novel social determinant of health that could adversely affect the functional well-being of older persons. Deficiencies in resource-poor environments can potentially be addressed through social and public health interventions.

OBJECTIVE

To evaluate whether estimates of active and disabled life expectancy differ on the basis of neighborhood disadvantage after accounting for individual-level socioeconomic characteristics and other prognostic factors.

DESIGN, SETTING, AND PARTICIPANTS

This prospective longitudinal cohort study included 754 nondisabled community-living persons, aged 70 years or older, who were members of the Precipitating Events Project in south central Connecticut from March 1998 to June 2020.

MAIN OUTCOMES AND MEASURES

Disability in 4 essential activities of daily living (bathing, dressing, walking, and transferring) was assessed each month. Scores on the Area Deprivation Index, a census-based socioeconomic measure with 17 education, employment, housing quality, and poverty indicators, were obtained through linkages with the 2000 Neighborhood Atlas. Area Deprivation Index scores were dichotomized at the 80th state percentile to distinguish neighborhoods that were disadvantaged (81-100) from those that were not (1-80).

RESULTS

Among the 754 participants, the mean (SD) age was 78.4 (5.3) years, and 487 (64.6%) were female. Within 5-year age increments from 70 to 90, active life expectancy was consistently lower in participants from neighborhoods that were disadvantaged vs not disadvantaged, and these differences persisted and remained statistically significant after adjustment for individual-level race and ethnicity, education, income, and other prognostic factors. At age 70 years, adjusted estimates (95% CI) for active life expectancy (in years) were 12.3 (11.5-13.1) in the disadvantaged group and 14.2 (13.5-14.7) in the nondisadvantaged group. At each age, participants from disadvantaged neighborhoods spent a greater percentage of their projected remaining life disabled, relative to those from nondisadvantaged neighborhoods, with adjusted values (SE) ranging from 17.7 (0.8) vs 15.3 (0.5) at age 70 years to 55.0 (1.7) vs 48.1 (1.3) at age 90 years.

CONCLUSIONS AND RELEVANCE

In this prospective longitudinal cohort study, living in a disadvantaged neighborhood was associated with lower active life expectancy and a greater percentage of projected remaining life with disability. By addressing deficiencies in resource-poor environments, new or expanded social and public health initiatives have the potential to improve the functional well-being of community-living older persons and, in turn, reduce health disparities in the US.

A Longitudinal Analysis of Functional Disability, Recovery, and Nursing Home Utilization After Hospitalization for Ambulatory Care Sensitive Conditions Among Community-Living Older Persons

BACKGROUND/OBJECTIVE

Hospitalizations for ambulatory care sensitive conditions (ACSCs) are considered potentially preventable. With little known about the functional outcomes of older persons after ACSC-related hospitalizations, our objectives were to describe: (1) the 6-month course of postdischarge functional disability, (2) the cumulative monthly probability of functional recovery, and (3) the cumulative monthly probability of incident nursing home (NH) admission.

METHODS

The analytic sample included 251 ACSC-related hospitalizations from a cohort of 754 nondisabled, community-living persons aged 70 years and older who were interviewed monthly for up to 19 years. Patient-reported disability scores in basic, instrumental, and mobility activities ranged from 0 to 13. Functional recovery was defined as returning within 6 months of discharge to a total disability score less than or equal to that immediately preceding hospitalization.

RESULTS

The mean age was 85.1 years, and the mean disability score was 5.4 in the month prior to the ACSC-related hospitalization. After the ACSC-related hospitalization, total disability scores peaked at month 1 and improved modestly over the next 5 months, but remained greater than the pre-hospitalization score. Functional recovery was achieved by 70% of patients, and incident NH admission was experienced by 50% within 6 months after the 251 ACSC-related hospitalizations.

CONCLUSIONS

During the 6 months after an ACSC-related hospitalization, older persons exhibited total disability scores that were higher than those immediately preceding hospitalization, with 3 of 10 not achieving functional recovery and half experiencing incident NH admission. These findings provide evidence that older persons experience clinically meaningful adverse patient-reported outcomes after ACSC-related hospitalizations.

Transitions between levels of dependency among older people receiving social care - a retrospective longitudinal cohort study in a Swedish municipality

Background

Knowledge is scarce on how needs for home help and special housing evolve among older people who begin to receive support from municipal social care. The purpose of this study was to describe baseline distributions and transitions over time between levels of dependency among older persons after being granted social care in a Swedish municipality.

Methods

Based on a longitudinal cohort study in a Swedish municipality, data was collected retrospectively from municipal records. All persons 65 years or older who received their first decision on social care during 2010 (n = 415) were categorized as being in mild, moderate, severe, or total dependency, and were observed until the end of 2013. Baseline distributions and transitions over time were described descriptively and analysed with survival analysis, with the Kaplan-Meier estimator, over the entire follow-up period. To test potential differences in relation to gender, we used the Cox-Proportional hazards model.

Results

Baseline distributions between mild, moderate, severe, and total dependency were 53, 16, 24, and 7.7%. During the first year, between 40 and 63% remained at their initial level of dependency. Among those with mild and moderate levels of dependency at baseline, a large proportion declined towards increasing levels of dependency over time; around 40% had increased their dependency level 1 year from baseline and at the end of the follow-up, 75% had increased their dependency level or died.

Conclusions

Older people in Sweden being allocated home help are at high risk for decline towards higher levels of dependency, especially those at mild or moderate dependency levels at baseline. Taken together, it is important that municipalities make use of existing knowledge so that they implement cost-effective preventative interventions for older people at an early stage before a decline toward increasing levels of dependency.

Functional Effects of Intervening Illnesses and Injuries After Hospitalization for Major Surgery in Community-living Older Persons

OBJECTIVE

To evaluate the functional effects of intervening illnesses and injuries, that is, events, in the year after major surgery.

BACKGROUND

Intervening events have pronounced deleterious effects on functional status in older persons, but have not been carefully evaluated after major surgery.

METHODS

From a cohort of 754 community-living persons, aged 70+ years, 317 admissions for major surgery were identified from 244 participants who were discharged from the hospital. Functional status (13 activities) and exposure to intervening hospitalizations, emergency department (ED) visits, and restricted activity were assessed each month. Comprehensive assessments (for covariates) were completed every 18 months.

RESULTS

In the year after major surgery, exposure rates (95% CI) per 100-person months to hospitalizations, ED visits, and restricted activity were 10.0 (8.0-12.5), 3.9 (2.8-5.4), and 12.3 (10.2-14.8) for functional recovery and 7.2 (6.1-8.5), 2.5 (1.9-3.2), 11.2 (9.8-12.9) for functional decline. Each of the 3 intervening events were independently associated with reduced recovery, with adjusted hazard ratios (95% CI) of 0.20 (0.09-0.47), 0.35 (0.15-0.81), and 0.57 (0.36-0.90) for hospitalizations, ED visits, and restricted activity. For functional decline, the corresponding odds ratios (95% CI) were 5.68 (3.87-8.33), 1.90 (1.13-3.20), and 1.30 (0.96-1.75). The effect sizes for hospitalizations and ED visits were larger than those for the covariates.

CONCLUSIONS

Intervening illnesses/injuries are common in the year after major surgery, and those leading to hospitalization and ED visit are strongly associated with adverse functional outcomes, with effect sizes larger than those of traditional risk factors.

Functional Effects of Intervening Illnesses and Injuries After Critical Illness in Older Persons

OBJECTIVES

Intervening illnesses and injuries have pronounced deleterious effects on functional status in older persons, but have not been carefully evaluated after critical illness. We set out to evaluate the functional effects of intervening illnesses and injuries in the year after critical illness.

DESIGN

Prospective longitudinal study of 754 nondisabled community-living persons, 70 years old or older.

SETTING

Greater New Haven, CT, from March 1998 to December 2018.

PATIENTS

The analytic sample included 250 ICU admissions from 209 community-living participants who were discharged from the hospital.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Functional status (13 activities) and exposure to intervening illnesses and injuries leading to hospitalization, emergency department visit, or restricted activity were assessed each month. Comprehensive assessments (for covariates) were completed every 18 months. In the year after critical illness, recovery of premorbid function was observed for 169 of the ICU admissions (67.6%), and the mean (sd) number of episodes of functional decline (from 1 mo to the next) was 2.2 (1.6). The adjusted hazard ratios (95% CI) for recovery were 0.18 (0.09-0.39), 0.46 (0.17-1.26), and 0.75 (0.48-1.18) for intervening hospitalizations, emergency department visits, and restricted activity, respectively. For functional decline, the corresponding odds ratios (95% CI) were 2.06 (1.56-2.73), 1.78 (1.12-2.83), and 1.25 (0.92-1.69). The effect sizes for hospitalization and emergency department visit were larger than those for any of the covariates.

CONCLUSIONS

In the year after critical illness, intervening illnesses and injuries leading to hospitalization and emergency department visit are strongly associated with adverse functional outcomes, with effect sizes larger than those of traditional risk factors. To improve functional outcomes, more aggressive efforts will be needed to prevent and manage intervening illnesses and injuries after critical illness.

Risk Factors for Disability After Emergency Department Discharge in Older Adults

OBJECTIVES

We have previously shown that older adults discharged from the emergency department (ED) experience an increased disability burden within a 6-month time period after ED discharge. The objective of this study was to identify risk factors associated with increased disability burden among older adults discharged from the ED.

METHODS

This study is part of an ongoing longitudinal study of 754 community-living persons aged ≥70 years. The analytic sample included 813 ED visits without hospitalization from 430 participants who had at least one visit to an ED during a 14-year follow-up period (1998-2012). Information on ED visits and disability burden in 13 functional activities was collected during monthly interviews. Twenty-nine candidate risk factors were evaluated for their independent associations with increased disability burden using a longitudinal multivariable model.

RESULTS

In the multivariable analyses, age ≥85 (adjusted risk ratio [aRR] = 1.14, 95% confidence interval [CI] = 1.05 to 1.24), being unmarried (aRR = 1.15, 95% CI = 1.05 to 1.27), lower-extremity weakness (aRR = 1.20, 95% CI = 1.07 to 1.34), and physical frailty (aRR = 1.25, 95% CI = 1.13 to 1.37) were associated with increased disability burden. As the number of risk factors increased, the predicted mean disability burden (on a scale of 0 to 13) also increased, ranging from a value of 1.80 (95% CI = 1.43 to 2.27) for 0 risk factors to a value of 8.59 (95% CI = 7.93 to 9.29) for four risk factors.

CONCLUSIONS

Among older adults discharged from the ED, several risk factors were associated with increased disability burden over the following 6 months, including age ≥85, being unmarried, lower-extremity weakness, and physical frailty. Further research is needed to evaluate whether risk stratification based on nonmodifiable factors or interventions targeting modifiable risk factors improve functional outcomes for older adults discharged from the ED.

Trends in Restricting Symptoms at the End of Life from 1998 to 2019: A Cohort Study of Older Persons

OBJECTIVES

To describe changes in the occurrence of restricting symptoms at the end of life from 1998 to 2019 and compare these changes according to the condition leading to death.

DESIGN

Prospective longitudinal study.

SETTING

Greater New Haven, CT.

PARTICIPANTS

A total of 665 decedents from a cohort of 754 community-living persons, 70 years or older.

MEASUREMENTS

The occurrence of 16 restricting symptoms was ascertained during monthly interviews. Information on the conditions leading to death was obtained from death certificates and comprehensive assessments that were completed every 18-months. For each restricting symptom, adjusted rates (per 100 person-months) were calculated separately for six multiyear time intervals.

RESULTS

From 1998 to 2019, rates decreased for five (31.3%) restricting symptoms (difficulty sleeping; chest pain or tightness; shortness of breath; cold or flu symptoms; and nausea, vomiting, or diarrhea), increased for three (18.8%: arm or leg weakness; urinary incontinence; and memory or thinking problem), and changed little for the other eight (50.0%: poor eyesight; anxiety; depression; musculoskeletal pain; fatigue; dizziness or unsteadiness; frequent or painful urination; and swelling in feet or ankles). The decrease in rates was most pronounced for shortness of breath, with a reduction from 15.0 (95% credible interval = 11.7-18.6) in 1998 to 2001 to 8.2 (95% credible interval = 5.9-10.5) in 2014 to 2019, yielding a rate ratio (95% credible interval) of 0.92 (0.86-0.98). When evaluated according to the condition leading to death, the results were similar, with 10 of the 13 statistically significant rate ratios representing decreases in rates over time and only 3 representing increases.

CONCLUSION

The occurrence of most restricting symptoms at the end of life has been decreasing or stable over the past two decades. These results suggest that end-of-life care has been improving, although additional efforts will be needed to further reduce symptom burden at the end of life.

Factors Associated With Insidious and Noninsidious Disability

BACKGROUND

Although disability is often precipitated by an illness/injury, it may arise insidiously. Our objectives were to identify the factors associated with the development of insidious and noninsidious disability and to determine whether these risk factors differ between the two types of disability.

METHODS

We prospectively evaluated 754 community-living persons, 70+ years, from 1998 to 2016. The unit of analysis was an 18-month person-interval, with risk factors assessed at the start of each interval. Disability in four activities of daily living and exposure to intervening events, defined as illnesses/injuries leading to hospitalization, emergency department visits, or restricted activity, were assessed each month. Insidious and noninsidious disability were defined based on the absence and presence of an intervening event.

RESULTS

The rate of noninsidious disability (21.7%) was twice that of insidious disability (10.8%). In multivariable recurrent-event Cox analyses, six factors were associated with both disability outcomes: non-Hispanic white race, lower extremity muscle weakness, poor manual dexterity, and (most strongly) frailty, cognitive impairment, and low functional self-efficacy. Three factors were associated with only noninsidious disability (older age, number of chronic conditions, and depressive symptoms), whereas four were associated with only insidious disability (female sex, lives with others, low SPPB score, and upper extremity weakness). The modest differences in risk factors identified for the two outcomes in multivariable analyses were less apparent in the bivariate analyses.

CONCLUSIONS

Although arising from different mechanisms, insidious and noninsidious disability share a similar set of risk factors. Interventions to prevent disability should prioritize this shared set of risk factors.

Factors Associated With Functional Recovery Among Older Survivors of Major Surgery

OBJECTIVE

The objectives of the current study were 2-fold: first, to evaluate the incidence and time to recovery of premorbid function within 6 months of major surgery and second, to identify factors associated with functional recovery among older persons who survive a major surgery with increased disability.

BACKGROUND

Most older persons would not choose a surgical treatment resulting in persistently increased postsurgical disability, even if survival was assured. Potential predictors of functional recovery after major surgery have, however, not been well-studied among geriatric patients.

METHODS

It is a prospective longitudinal study of 754 community-living persons 70 years or older. The analytic sample included 266 person-admissions in which participants survived major surgery with increased disability and were monitored on a monthly basis for 6 months.

RESULTS

Of the 266 person-admissions assessed, 174 (65.4%) recovered to their presurgical level of function, with median time to recovery of 2 months (interquartile range, 1-3), whereas 16 (6.0%) died. Two factors were significantly associated with an increased likelihood of functional recovery: being nonfrail (hazard ratio 1.60; 95% confidence interval 1.03-2.51; P = 0.038) and having elective surgery (hazard ratio 1.72; 95% confidence interval 1.14-2.59; P = 0.009). Three factors were associated with a reduced likelihood of functional recovery: hearing impairment, greater increase in postsurgical disability in the month after hospital discharge, and years of education.

CONCLUSIONS

Among older persons, nonfrailty and elective surgery were positively associated with functional recovery, whereas hearing impairment, greater increases in postsurgical disability, and years of education were associated with higher risk of protracted disability.

Short-Term Disability Fluctuations in Late Life

OBJECTIVES

Late-life disability is highly dynamic but within-person short-term fluctuations have not been assessed previously. We analyze how substantial such late-life disability fluctuations are and whether they are associated with time-to-death, long-term disability trajectories, frailty, and sociodemographics.

METHODS

Monthly survey data (Precipitating Events Project Study) on activities of daily living/instrumental activities of daily living (ADL/IADL) disability (0-9) in the last years of life from 642 deceased respondents providing 56,308 observations were analyzed with a two-step approach. Observation-level residuals extracted from a Poisson mixed regression model (first step), which depict vertical short-term fluctuations from individual long-term trajectories, were analyzed with a linear mixed regression model (second step).

RESULTS

Short-term disability fluctuations amounted to about one ADL/IADL limitation, increased in the last 4 years of life, and were closely associated with disability increases. Associations with frailty or sociodemographics characteristics were absent except for living alone.

DISCUSSION

Short-term disability fluctuations in late life were substantial, were linked to mortality-related processes, and represent a concomitant feature of disability increases in late life.

Recovery from Severe Disability that Develops Progressively Versus Catastrophically: Incidence, Risk Factors, and Intervening Events

BACKGROUND

Few prior studies have evaluated recovery after the onset of severe disability or have distinguished between the two subtypes of severe disability.

OBJECTIVES

To identify the risk factors and intervening illnesses and injuries (i.e., events) that are associated with reduced recovery after episodes of progressive and catastrophic severe disability.

DESIGN

Prospective longitudinal study of 754 nondisabled community-living persons, aged 70 years or older.

SETTING

Greater New Haven, CT, March 1998 to December 2016.

PARTICIPANTS

A total of 431 episodes of severe disability were evaluated from 385 participants: 116 progressive (115 participants) and 315 catastrophic (270 participants).

MEASUREMENTS

Candidate risk factors were assessed every 18 months. Functional status and exposure to intervening events leading to hospitalization, emergency department visit, or restricted activity were assessed each month. Severe disability was defined as the need for personal assistance with three or more of four essential activities of daily living. Recovery was defined as return to independent function (no disability) within 6 months of developing severe disability.

RESULTS

Recovery occurred among 35.3% (95% confidence interval [CI] = 26.0%-48.0%) and 61.6% (95% CI = 53.5%-70.9%) of the 116 progressive and 315 catastrophic severe disability episodes, respectively. In the multivariable analyses, lives alone, frailty, and intervening hospitalization were each independently associated with reduced recovery from progressive disability, with adjusted hazard ratios (95% CIs) of 0.31 (0.15-0.64), 0.23 (0.12-0.45), and 0.27 (0.08-0.95), respectively, whereas low functional self-efficacy, intervening restricted activity, and intervening hospitalization were each independently associated with reduced recovery from catastrophic disability, with adjusted hazard ratios (95% CIs) of 0.56 (0.40-0.81), 0.55 (0.35-0.85), and 0.45 (0.31-0.66), respectively.

CONCLUSIONS

Recovery of independent function is considerably more likely after the onset of catastrophic than progressive severe disability, the risk factors for reduced recovery differ between progressive and catastrophic severe disability, and subsequent exposure to intervening illnesses and injuries considerably diminishes the likelihood of recovery from both subtypes of severe disability.

Risk Factors and Precipitants of Severe Disability Among Community-Living Older Persons

IMPORTANCE

Severe disability greatly diminishes quality of life and often leads to a protracted period of long-term care or death, yet the processes underlying severe disability have not been fully evaluated.

OBJECTIVE

To evaluate potential risk factors and precipitants associated with severe disability that develops progressively (during ≥2 months) vs catastrophically (from 1 month to the next).

DESIGN, SETTING, AND PARTICIPANTS

Prospective cohort study conducted in greater New Haven, Connecticut, from March 1998 to December 2016, with 754 nondisabled community-living persons aged 70 years or older. Data analysis was conducted from November 2018 to May 2019.

MAIN OUTCOMES AND MEASURES

Candidate risk factors were assessed every 18 months. Functional status and potential precipitants, including illnesses or injuries leading to hospitalization, emergency department visit, or restricted activity, were assessed each month. Severe disability was defined as the need for personal assistance with at least 3 of 4 essential activities of daily living. The analysis was based on person-months within 18-month intervals.

RESULTS

The mean (SD) age for the 754 participants was 78.4 (5.3) years, 487 (64.6%) were women, and 683 (90.5%) were non-Hispanic white participants. The incidence of progressive and catastrophic severe disability was 3.5% and 9.7%, respectively, based on 3550 intervals. In multivariable analysis, 6 risk factors were independently associated with progressive disability (≥85 years: hazard ratio [HR], 1.6; 95% CI, 1.1-2.4; hearing impairment: HR, 1.7; 95% CI, 1.0-2.8; frailty: HR, 2.4; 95% CI, 1.6-3.7; cognitive impairment: HR, 2.0; 95% CI, 1.3-3.1; low functional self-efficacy: HR, 1.8; 95% CI, 1.2-2.8; low peak flow: HR, 1.7; 95% CI, 1.2-2.4), and 4 were independently associated with catastrophic disability (visual impairment: HR, 1.4; 95% CI, 1.1-1.8; hearing impairment: HR, 1.3; 95% CI, 1.0-1.7; poor physical performance: HR, 1.8; 95% CI, 1.3-2.5; low peak flow: HR, 1.3; 95% CI, 1.0-1.7). The associations of the precipitants were much more pronounced than those of the risk factors, with HRs as high as 321.4 (95% CI, 194.5-531.0) for hospitalization and catastrophic disability and 48.3 (95% CI, 31.0%-75.4%) for hospitalization and progressive disability. Elimination of an intervening hospitalization was associated with a decrease in the risk of progressive and catastrophic severe disability of 3.0% (95% CI, 3.0%-3.1%) and 12.3% (95% CI, 12.1%-12.5%), respectively. Risk differences were 0.6% (95% CI, 0.6%-0.6%) and 1.3% (95% CI, 1.3%-1.4%) for emergency department visit and 0.1% (95% CI, 0.1%-0.2%) and 0.4% (95% CI, 0.4%-0.4%) for restricted activity, and ranged from 0.1% (95% CI, 0.1%-0.1%) to 0.3% (95% CI, 0.3%-0.3%) for the independent risk factors, for progressive and catastrophic disability, respectively.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that whether it develops progressively or catastrophically, severe disability among older community-living adults arises most commonly in the setting of an intervening illness or injury. To reduce the burden of severe disability, more aggressive efforts will be needed to prevent and manage intervening illnesses or injuries and to facilitate recovery after these debilitating events.

Effects of comorbid physical frailty and low muscle mass on incident disability in community-dwelling older adults: A 24-month follow-up longitudinal study

OBJECTIVES

Low muscle mass frequently precedes or coexists with physical frailty in late life. This study aimed to examine whether comorbid physical frailty and low muscle mass increase the risk of incident disability in community-dwelling older adults.

STUDY DESIGN

A prospective cohort study.

METHODS

Participants were 9229 community-dwelling older Japanese adults (≥65 years). Longitudinal data on incident disability were collected for up to a maximum of 24 months from baseline. Physical frailty was defined as experiencing three or more of the following five symptoms: slowness, weakness, exhaustion, low activity, and weight loss. Low muscle mass was identified based on the AWGS definition (<7.0 kg/m² for men and <5.7 kg/m² for women).

RESULTS

During the follow-up period, 460 (5.0%) individuals had incident disability. The prevalence rates of low muscle mass, physical frailty, and comorbid physical frailty and low muscle mass were 12.0% (n = 1104), 6.8 % (n = 624), and 1.8 % (n = 167), respectively. Compared with non-physical frailty/normal muscle mass, physical frailty (hazard ratio (HR) 2.50, 95% confidential interval (CI) 1.97-3.18) and comorbid physical frailty and low muscle mass (HR 4.03, 95% CI 2.85-5.70) were significantly associated with incident disability after adjusting for the covariates.

CONCLUSIONS

Although low muscle mass alone may not be associated with an increased risk of incident disability in community-dwelling older adults, comorbid physical frailty and low muscle mass had a significant impact on disability. Low muscle mass was a risk factor for disability in older adults with physical frailty.

Disability and Recovery After Hospitalization for Medical Illness Among Community-Living Older Persons: A Prospective Cohort Study

OBJECTIVES

To determine for each basic, instrumental, and mobility activity after hospitalization for acute medical illness: (1) disability prevalence immediately before and monthly for 6 months after hospitalization; (2) disability incidence 1 month after hospitalization; and (3) recovery time from incident disability during months 2 to 6 after hospitalization.

DESIGN

Prospective cohort study.

SETTING

New Haven, Connecticut.

PARTICIPANTS

A total of 515 community-living persons, mean age 82.7 years, hospitalized for acute noncritical medical illness and alive within 1 month of hospital discharge.

MEASUREMENTS

Disability was defined monthly for each basic (bathing, dressing, walking, transferring), instrumental (shopping, housework, meal preparation, taking medications, managing finances), and mobility activity (walking a quarter mile, climbing flight of stairs, lifting/carrying 10 pounds, driving) if help was needed to perform the activity or if a car was not driven in the prior month.

RESULTS

Disability was common 1 and 6 months after hospitalization for activities frequently involved in leaving the home to access care including walking a quarter mile (prevalence 65% and 53%, respectively) and driving (65% and 61%). Disability was also common for activities involved in self-managing chronic health conditions including meal preparation (53% and 41%) and taking medications (41% and 31%). New disability was common and often prolonged. For example, 43% had new disability walking a quarter mile, and 30% had new disability taking medications, with mean recovery time of 1.9 months and 1.7 months, respectively. Findings were similar for the subgroup of persons residing at home (ie, not in a nursing home) at the first monthly follow-up interview after hospitalization.

CONCLUSION

Disability in specific functional activities important to leaving home to access care and self-managing health conditions is common, often new, and present for prolonged time periods after hospitalization for acute medical illness. Post-discharge care should support patients through extended periods of vulnerability beyond the immediate transitional period. J Am Geriatr Soc 68:486-495, 2020.

Determinants of Maintenance and Recovery of Function in a Representative Older Community-Resident Biracial Sample

OBJECTIVES

Focus on decline in performance of activities of daily living (ADL) has not been matched by studies of recovery of function. Advised by a broad conceptual model of physical resilience, we ascertain characteristics that identify (1) maintenance, (2) decline, and (3) recovery of personal self-maintenance activities over six years in an older, community representative, African American and white sample.

DESIGN

Longitudinal study, analyses included descriptive statistics and repeated measures proportional hazards.

SETTING/PARTICIPANTS

Community-representative participants of the Duke Established Populations for Epidemiologic Studies of the Elderly (EPESE), unimpaired at baseline (n = 3187; 46% white, 54% African American; 64% female, 36% male), followed annually for up to 6 years.

MEASURES

Data included information on basic activities of daily living (BADL), demographic characteristics, health status, social services provided and received, household size, neighborhood safety, and survival status.

RESULTS

Over 6 years, ∼75% remained unimpaired, of whom 30% were unimpaired when they dropped out or died. Of ∼25% who became impaired, just under half recovered. Controlled analyses indicated that those who became impaired were in poorer health, younger, and more likely to be African American. Characteristics of recovery included younger age, not hospitalized in the previous year, and larger household size.

CONCLUSIONS/IMPLICATIONS

Maintenance of health status facilitated continued unimpaired BADL. While decline was associated with poorer health, younger age, and being African American, recovery was also associated with younger age, together with larger household size, and no further deterioration in health as measured here. Maintenance of good health is preferred, but following decline in functioning, increased effort to improve health and avoid further decline, which takes into account not only physical but also personal social conditions, is needed.

Cohort Profile: The Precipitating Events Project (PEP Study)

The Precipitating Events Project (PEP Study) is an ongoing longitudinal study of 754 nondisabled community-living persons age 70 years or older who were members of a large health plan in greater New Haven, Connecticut, USA. The study was established to rigorously evaluate the epidemiology of disability in older persons and to elucidate the role of intervening illnesses and injuries on the disabling process. Of the eligible members, 75.2% agreed to participate and were enrolled between March 1998 and October 1999. Participants have completed comprehensive home-based assessments at 18-month intervals and have been interviewed monthly over the phone with a completion rate of 99%. Detailed participant-level data on health care utilization are obtained annually through linkages with Medicare claims. Through June 2019, 702 (93.1%) participants have died after a median of 109 months, while 43 (5.7%) have dropped out of the study after a median of 27 months. Death certificates are available for all decedents. To date, 117 original reports have been published using data from the PEP Study, including many focusing on other high priority areas such as end of life, frailty, depressive symptoms, aging stereotypes, pain, sleep, and methodologic research. The PEP Study welcomes proposals to access data for meritorious analyses from qualified investigators.

Functional Trajectories Before and After Major Surgery in Older Adults

OBJECTIVES

We hypothesized that distinct sets of functional trajectories can be identified in the year before and after major surgery, with unique transition probabilities from pre to postsurgical functional trajectories, and that outcomes would be better among participants undergoing elective versus nonelective surgery.

BACKGROUND

Major surgery is common and can be highly morbid in older persons. The relationship between the course of disability (ie, functional trajectory) before and after surgery in older adults has not been well-studied for most operations.

METHODS

Prospective cohort study of 754 community-living persons 70 years or older. The analytic sample included 250 participants who underwent their first major surgery during the study period.

RESULTS

Before surgery, 4 functional trajectories were identified: no disability (n = 60, 24.0%), and mild (n = 84, 33.6%), moderate (n = 73, 29.2%), and severe (n = 33, 13.2%) disability. After surgery, 4 functional trajectories were identified: rapid (n = 39, 15.6%), gradual (n = 76, 30.4%), partial (n = 70, 28.0%), and little (n = 57, 22.8%) improvement. Rapid improvement was seen for n = 31 (51.7%) participants with no disability before surgery, but was uncommon among those with mild disability (n = 8, 9.5%) and was not observed in the moderate and severe trajectory groups. For participants with mild to moderate disability before surgery, gradual improvement (n = 46, 54.8%) and partial improvement (n = 36, 49.3%) were most common. Most participants with severe disability (n = 27, 81.8%) before surgery exhibited little improvement. Outcomes were better for participants undergoing elective versus nonelective surgery.

CONCLUSIONS

Functional prognosis in the year after major surgery is highly dependent on premorbid function.

Taking to Bed at the End of Life

OBJECTIVES

To evaluate the time course of "taking to bed" at the end of life and determine whether it differs according to age, sex, and condition leading to death.

DESIGN

Prospective longitudinal study.

SETTING

Greater New Haven, Connecticut.

PARTICIPANTS

A total of 651 decedents from a cohort of 754 community-living persons, 70+ years of age.

MEASUREMENTS

During the last 2 years of life, the occurrence of bed rest and number of days in bed, two indicators of bed rest burden, were ascertained each month. Bed rest was defined as staying in bed for at least a half day due to an illness, injury, or other problem.

RESULTS

The occurrence of bed rest increased modestly from 12.4% at 24 months before death to 19.0% at 5 months before death, before increasing exponentially to 51.6% at 1 month before death. The median number of days in bed fluctuated within a narrow range of 3 to 7 from 24 months to 4 months before death, before increasing substantially to a high of 14 at 1 month before death. In the last 2 years of life, the burden of bed rest did not differ by age but was significantly greater in women than men. Among the conditions leading to death, the burden of bed rest was highest among persons dying from organ failure and cancer, lowest for sudden death, and intermediate for frailty, advanced dementia, and other conditions.

CONCLUSION

The burden of bed rest at the end of life is greater in women than men, does not differ by age, and is highest among persons dying from organ failure and cancer. The steep increases observed in the last 3 to 5 months of life suggest that taking to bed may be an indicator that death is approaching and should prompt discussions about referral to hospice among older persons with serious illness.

Days Spent at Home in the Last Six Months of Life Among Community-Living Older Persons

BACKGROUND

Days spent at home has recently been identified as an important patient-centered outcome; yet, relatively little is known about time spent at home at the end of life among community-living older persons.

METHODS

The analytic sample included 457 decedents from an ongoing cohort study of 754 community-living persons, aged ≥70 years. Days spent at home were calculated as 180 days minus the number of days in a hospital, nursing home, or hospice facility. The condition leading to death was determined from death certificates and comprehensive assessments.

RESULTS

The median number of days at home was 159 (interquartile range 125-174). There were 138 (30.2%) decedents at home during the entire 6-month period, while 163 (35.7%) were at home for fewer than 150 days. Days at home did not differ significantly by age (P = .922), sex (P = .238), or race/ethnicity (P = .199), but did differ according to the condition leading to death (P = .001), with the lowest value observed for organ failure (150 [106.5-168.5]), highest values for sudden death (177 [172-179]) and cancer (167 [140-174]), and intermediate values for advanced dementia (164 [118-174]), frailty (160.5 [130-174]), and other conditions (153 [118-175]).

CONCLUSIONS

Among community-living older persons, days spent at home in the last 6 months of life do not differ by age, sex, or race/ethnicity, but are significantly lower for persons dying from organ failure. Additional efforts may be warranted to optimize time spent at home at the end of life, especially among older persons dying from organ failure.

Affective problems and decline in cognitive state in older adults: a systematic review and meta-analysis

Evidence suggests that affective problems, such as depression and anxiety, increase risk for late-life dementia. However, the extent to which affective problems influence cognitive decline, even many years prior to clinical diagnosis of dementia, is not clear. The present study systematically reviews and synthesises the evidence for the association between affective problems and decline in cognitive state (i.e., decline in non-specific cognitive function) in older adults. An electronic search of PubMed, PsycInfo, Cochrane, and ScienceDirect was conducted to identify studies of the association between depression and anxiety separately and decline in cognitive state. Key inclusion criteria were prospective, longitudinal designs with a minimum follow-up period of 1 year. Data extraction and methodological quality assessment using the STROBE checklist were conducted independently by two raters. A total of 34 studies (n = 71 244) met eligibility criteria, with 32 studies measuring depression (n = 68 793), and five measuring anxiety (n = 4698). A multi-level meta-analysis revealed that depression assessed as a binary predictor (OR 1.36, 95% CI 1.05-1.76, p = 0.02) or a continuous predictor (B = -0.008, 95% CI -0.015 to -0.002, p = 0.012; OR 0.992, 95% CI 0.985-0.998) was significantly associated with decline in cognitive state. The number of anxiety studies was insufficient for meta-analysis, and they are described in a narrative review. Results of the present study improve current understanding of the temporal nature of the association between affective problems and decline in cognitive state. They also suggest that cognitive function may need to be monitored closely in individuals with affective disorders, as these individuals may be at particular risk of greater cognitive decline.

The Competing Risk of Death in Longitudinal Geriatric Outcomes

OBJECTIVES

To address the competing risk of death in longitudinal studies of older persons, we demonstrate sensitivity analyses that evaluate robustness of associations between exposures and three outcome types: dichotomous, count, and time to event.

DESIGN

A secondary analysis of data from a prospective cohort study.

SETTING

Community-based data from the Precipitating Events Project in New Haven, CT.

PARTICIPANTS

Persons 70 years and older who were initially community dwelling and without disability in the four basic activities of daily living (N = 754).

MEASUREMENTS

Missing outcome values from decedents were multiply imputed under different scenarios. Three outcomes were examined: dichotomous fall-related hospitalization (FRH); a count (0-13) of total disability in each of the 6 months after discharge; and days to functional recovery among those whose disability worsened in the hospital. Each outcome had a different exposure: for dichotomous, indicators of being overweight or obese; for count, frailty from the Fried phenotype (0-5, where not frail = 0, prefrail = 1-2, and frail = 3-5); for days to recovery, vision impairment.

RESULTS

For FRH, being overweight or obese lost significance when decedents were kept in the risk pool without outcome events for over 10 years. For disability count and time to recovery, with follow-up of 6 months, exposures only lost significance under highly implausible clinical scenarios.

CONCLUSION

This method facilitates evaluation of potential bias from the competing risk of death in longitudinal studies for nondeath outcomes that are not necessarily time to event. Results suggest that death introduces substantive bias when long-term follow-up results in cumulatively high levels of mortality. J Am Geriatr Soc 67:357-362, 2019.

Burden of Restricted Activity and Associated Symptoms and Problems in Late Life and at the End of Life

OBJECTIVES

To compare rates of restricted activity and associated symptoms and problems in the last 6 months of life with those in the period before the last 6 months of life.

DESIGN

Prospective cohort study.

SETTING

Greater New Haven, Connecticut.

PARTICIPANTS

Community-living persons aged 70 and older (N=754).

MEASUREMENTS

The occurrence of restricted activity (staying in bed for at least half the day or cutting down on usual activities) and 24 prespecified symptoms and problems leading to restricted activity was ascertained monthly for nearly 19 years.

RESULTS

Rates of restricted activity per 100 person-months were 36.5 in the last 6 months of life versus 16.1 in the period before the last 6 months of life (P<.001). Of 737 participants with 1 month or more of restricted activity, rates of restricting symptoms per 100 person-months of restricted activity ranged from 8.0 for frequent or painful urination to 65.6 for been fatigued, and rates of restricting problems ranged from 0.1 for problem with alcohol to 23.4 for been afraid of falling. Rates were significantly higher in the last 6 months of life than in the prior period for 13 of the 24 restricting symptoms and problems (P<.05), most notably for shortness of breath (38.6 vs 21.8), weakness (37.3 vs 18.9), and confusion (31.2 vs 9.8). Mean (standard error) number of restricting symptoms and problems was significantly higher in the last 6 months of life (6.1 (0.1)) than in the prior period (4.7 (0.03)) (P<.001).

CONCLUSION

Rates of restricted activity and associated symptoms and problems are substantially greater in the last 6 months of life than in the period before the last 6 months of life. Enhanced palliative care strategies may be needed to diminish the burden of distressing symptoms and problems at the end of life. J Am Geriatr Soc 66:2282-2288, 2018.

Transitory and Enduring Disability Among Urban and Rural People

BACKGROUND

Disabilities are not evenly distributed across geography or age, yet few studies on disability have considered these factors. The purpose of this study was to explore rural-urban differences in disability rates, particularly related to gender and race, and what other rural-urban disparities help explain these differences.

METHODS

Utilizing the 2008-2016 Current Population Survey (CPS), we first examined rural and urban disability trends by gender and race, estimating means and rural-urban percentage differences for men and women by race and conducting t test analysis to test group differences by age cohort (eg, comparing white, non-Hispanic, rural 15- to 24-year-old women to white, non-Hispanic, urban 15- to 24-year-old women). We then conducted a logistic regression to explore whether or not the effects of rurality on disability rates could be explained by rural-urban differences in demographic and socioeconomic characteristics.

RESULTS

Descriptively, rural people report disability at higher rates than urban people across nearly all age category, gender, and racial combinations. These differences are more pronounced for nonwhite respondents in middle to older age categories. Additionally, while some of the rural disability disparity can be explained by adding demographic and socioeconomic variables to the logistic regression model, the effect of rurality remains significant.

CONCLUSIONS

Our findings suggest that when researchers, policy makers, and service providers are addressing rural and urban differences in health and well-being, self-reported disability is another factor to consider. Future work should be mindful of how disability and space intersect with gender and race, creating significant disparities for people of color in rural places.

Diet and Activity Assessments and Interventions Using Technology in Older Adults

This paper reports on the findings and recommendations specific to older adults from the "Tech Summit: Innovative Tools for Assessing Diet and Physical Activity for Health Promotion" forum organized by the North American branch of the International Life Sciences Institute. The summit aimed to investigate current and emerging challenges related to improving energy balance behavior assessment and intervention via technology. The current manuscript focuses on how novel technologies are applied in older adult populations and enumerated the barriers and facilitators to using technology within this population. Given the multiple applications for technology in this population, including the ability to monitor health events and behaviors in real time, technology presents an innovative method to aid with the changes associated with aging. Although older adults are often perceived as lacking interest in and ability to adopt technologies, recent studies show they are comfortable adopting technology and user uptake is high with proper training and guided facilitation. Finally, the conclusions suggest recommendations for future research, including the need for larger trials with clinical outcomes and more research using end-user design that includes older adults as technology partners who are part of the design process.

THEME INFORMATION

This article is part of a theme issue entitled Innovative Tools for Assessing Diet and Physical Activity for Health Promotion, which is sponsored by the North American branch of the International Life Sciences Institute.

Prognostic Effect of Changes in Physical Function Over Prior Year on Subsequent Mortality and Long-Term Nursing Home Admission

OBJECTIVES

To evaluate the prognostic effect of changes in physical function at different intervals over the prior year on subsequent outcomes after accounting for present function.

DESIGN

Prospective longitudinal study.

SETTING

Greater New Haven, Connecticut, from March 1998 to January 2006.

PARTICIPANTS

Community-living persons aged 71 and older who completed an 18-month comprehensive assessment (N=658).

MEASUREMENTS

Disability in 13 activities of daily living, instrumental activities of daily living, and mobility activities was assessed at the 18-month comprehensive assessment and at 12, 6, and 3 months before 18 months. Time to death and long-term nursing home admission, defined as 3 months and longer, were ascertained for up to 5 years after 18 months.

RESULTS

In the bivariate models, disability at 18 months and change in disability between 18 months and each of the 3 prior time-points (12, 6, 3 months) were significantly associated with time to death. The risk of death, for example, increased by 24% for each 1-point increase in 18-month disability score (on a scale from 0 to 13) and by 22% for each 1-point change in disability score between 18 months and prior 12 months (on a scale from -13 to 13). In a set of multivariable models with and without covariates, the associations were maintained for 18-month disability but not for change in disability between 18 months and each of the 3 prior time-points. The results were comparable for time to long-term nursing home admission except that 2 of the associations were not statistically significant.

CONCLUSION

When evaluating risk of adverse outcomes, such as death and long-term nursing home admission, an assessment of change in physical function at different intervals over the prior year, although a strong bivariate predictor, did not provide useful prognostic information beyond that available from current level of function.

Joint Trajectories of Cognition and Frailty and Associated Burden of Patient-Reported Outcomes

OBJECTIVES

To evaluate joint trajectories of cognition and frailty and their association with the cumulative burden of patient-reported outcomes, including hospitalization, nursing home admission, and disability.

DESIGN

Longitudinal study of 754 community-living persons aged 70 or older.

PARTICIPANTS

690 participants who had a baseline and at least one follow-up assessment of cognition and frailty between 1998 and 2009.

MEASUREMENTS

Cognition was assessed using the Mini-Mental State Examination (MMSE). Frailty was defined by the 5 criteria for the Fried phenotype: muscle weakness, exhaustion, low physical activity, shrinking, and slow walking speed. A group-based, mixture modeling approach was used to fit the joint trajectories of cognition and frailty. The cumulative burden of hospitalization, nursing home admission, and disability over 141 months associated with the joint trajectories was evaluated using a series of generalized estimating equation Poisson models.

RESULTS

Four joint trajectories were identified, including No cognitive frailty (27.8%), Slow cognitive decline and progressive frailty (45.5%), Rapid cognitive decline and progressive frailty (20.2%), and Cognitive frailty (6.5%). For each joint trajectory group, the interval-specific incidence density rates of all patient-reported outcomes tended to increase over time, with the exception of hospitalization for which the increasing trend was apparent only for the Slow cognitive decline and progressive frailty group. The No cognitive frailty group had the lowest cumulative burden of all patient-reported outcomes [eg, nursing home admissions, 7.5/1000 person-months, 95% confidence interval (CI): 4.8-11.7], whereas the Cognitive frailty group had the highest cumulative burden (eg, nursing home admissions, 381.1/1000 person-months, 95% CI: 294.5-493.1), with the exception of hospitalization. Compared with the No cognitive frailty group, the 3 other joint trajectory groups all had significantly greater burden of the patient-reported outcomes.

CONCLUSION

Community-living older persons exhibit distinct joint trajectories of cognition and frailty and experience an increasing burden of nursing home admission and disability as they age, with the greatest burden for those on a cognitive frailty trajectory.

The Association of Frailty With Post-ICU Disability, Nursing Home Admission, and Mortality: A Longitudinal Study

BACKGROUND

Frailty is a strong indicator of vulnerability among older persons, but its association with ICU outcomes has not been evaluated prospectively (ie, with objective measurements obtained prior to ICU admission). Our objective was to prospectively evaluate the relationship between frailty and post-ICU disability, incident nursing home admission, and death.

METHODS

The parent cohort included 754 adults aged ≥ 70 years, who were evaluated monthly for disability in 13 functional activities and every 18 months for frailty (1998-2014). Frailty was assessed using the Fried index, where frailty, prefrailty, and nonfrailty were defined, respectively, as at least three, one or two, and zero criteria (of five). The analytic sample included 391 ICU admissions.

RESULTS

The mean age was 84.0 years. Frailty and prefrailty were present prior to 213 (54.5%) and 140 (35.8%) of the 391 admissions, respectively. Relative to nonfrailty, frailty was associated with 41% greater disability over the 6 months following a critical illness (adjusted risk ratio, 1.41; 95% CI, 1.12-1.78); prefrailty conferred 28% greater disability (adjusted risk ratio, 1.28; 95% CI, 1.01-1.63). Frailty (odds ratio, 3.52; 95% CI, 1.23-10.08), but not prefrailty (odds ratio, 2.01; 95% CI, 0.77-5.24), was associated with increased nursing home admission. Each one-point increase in frailty count (range, 0-5) was associated with double the likelihood of death (hazard ratio, 2.00; 95% CI, 1.33-3.00) through 6 months of follow-up.

CONCLUSIONS

Pre-ICU frailty status was associated with increased post-ICU disability and new nursing home admission among ICU survivors, and death among all admissions. Pre-ICU frailty status may provide prognostic information about outcomes after a critical illness.

Disability in prison activities of daily living and likelihood of depression and suicidal ideation in older prisoners

OBJECTIVE

The study objective was to determine if disability in activities of daily living specific to prison, prison activities of daily living (PADLs), is associated with depression and severity of suicidal ideation (SI) in older prisoners, a rapidly growing population at high risk of suicide.

METHODS

Cross-sectional design using data from a study of prisoners age ≥50 years (N = 167). Depression was operationalized as a score of ≥15 on the 9-item Physician Health Questionnaire (PHQ-9). SI severity was assessed using the Geriatric Suicide Ideation Scale (GSIS). Participants were considered to have PADL disability if they reported any of the following as "very difficult" or "cannot do:" dropping to the floor for alarms, climbing on/off the top bunk, hearing orders, walking while wearing handcuffs, standing in line for medications, and walking to chow. Associations were examined with bivariate tests and with multivariable logistic and linear regression models, and the interaction term gender × PADL disability was tested.

RESULTS

PADL disability was associated with depression and SI severity. There was no main effect of gender on either depression or SI, yet the association between PADL disability and depression was considerably stronger in male than in female older prisoners.

CONCLUSIONS

Identifying older prisoners who have difficulty performing PADLs may help distinguish prisoners who may also be likely to be depressed or experience more severe SI. Furthermore, the association between PADL disability and depression may be particularly salient in older male prisoners. Longitudinal studies are needed as causal inferences are limited by the cross-sectional design. Copyright © 2016 John Wiley & Sons, Ltd.

Distressing Symptoms, Disability, and Hospice Services at the End of Life: Prospective Cohort Study

OBJECTIVES

To evaluate the relationship between the presence and number of restricting symptoms and number of disabilities and subsequent admission to hospice at the end of life.

DESIGN

Prospective cohort study.

SETTING

Greater New Haven, Connecticut, from March 1998 to December 2014.

PARTICIPANTS

Decedents from a cohort of 754 persons aged 70 and older (N = 562).

MEASUREMENTS

Hospice admissions were identified primarily from Medicare claims, and 15 restricting symptoms and disability in 13 activities were assessed during monthly interviews.

RESULTS

During their last year of life, 244 (43.4%) participants were admitted to hospice. The median duration of hospice was 12.5 days (interquartile range 4-43 days). Although the largest increases were observed in the last 2 months of life, the prevalence of restricting symptoms and mean number of restricting symptoms and disabilities in the preceding months were high and trending upward. During a specific month, the likelihood of hospice admission increased by 66% (adjusted hazard ratio (aHR) = 1.66, 95% confidence interval (CI) = 1.30-2.12) in the setting of any restricting symptoms, by 9% (aHR = 1.09, 95% CI = 1.05-1.12) for each additional restricting symptom, and by 10% (aHR = 1.10, 95% CI = 1.05-1.14) for each additional disability. Each additional month with any restricting symptoms increased the likelihood of hospice admission by 7% (aHR = 1.07, 95% CI = 1.01-1.13).

CONCLUSION

Hospice services appear to be suitably targeted to older persons with the greatest needs at the end of life, although the short duration of hospice suggests that additional strategies are needed to better address the high burden of distressing symptoms and disability at the end of life.

Restricting Back Pain and Subsequent Disability in Activities of Daily Living Among Community-Living Older Adults

OBJECTIVE

To evaluate the relationship between back pain severe enough to restrict activity (restricting back pain) and subsequent disability in essential (e) and instrumental (i) activities of daily living (ADL) among community-living older adults.

METHOD

In this prospective cohort study, we evaluated 754 adults, aged ≥70 years who were initially nondisabled in eADL. Restricting back pain and disability were assessed during monthly interviews for up to 159 months. Associations between restricting back pain and subsequent eADL and iADL disability were evaluated using recurrent events Cox models, adjusted for fixed-in-time and time-varying covariates.

RESULTS

Strong associations were found between restricting back pain and eADL and iADL disability, with hazard ratios (95% confidence intervals) of 3.47 [3.01, 3.90] and 2.33 [2.08, 2.61], respectively.

DISCUSSION

Restricting back pain was independently associated with subsequent disability in eADL and iADL. Interventions focused on decreasing restricting back pain in older adults may have the potential to reduce the subsequent burden of disability.

The subsequent course of disability in older persons discharged to a skilled nursing facility after an acute hospitalization

OBJECTIVES

To evaluate the association between the type of acute hospitalization and subsequent course of disability in older persons discharged to a skilled nursing facility (SNF).

DESIGN

Longitudinal study of 754 community-living persons aged 70 or older.

PARTICIPANTS

The analytical sample included 365 participants who had one or more admissions to a SNF after an acute hospitalization (n=520 index admissions).

MEASUREMENTS

Information on hospitalizations, SNF admissions, and disability was ascertained over 15years. The primary and secondary outcomes were disability burden and recovery of pre-hospital function, respectively, assessed monthly over a 6-month period. Index admissions were classified into four mutually exclusive groups based on the type of hospitalization: elective major surgery, non-elective major surgery, critical illness, and other.

RESULTS

Disability worsened considerably after hospitalization for each of the four groups. Relative to elective major surgery, the disability burden over 6months was significantly greater for non-elective major surgery, critical illness, and other hospitalizations, with adjusted rate ratios (RRs) of 1.37 (95% CI 1.19 to 1.59), 1.37 (95% CI 1.19 to 1.58), and 1.29 (95% CI 1.14 to 1.47), respectively. Overall, recovery to pre-hospital function was observed in only 132 (25.4%) admissions. Relative to elective major surgery, the likelihood of recovering pre-hospital function was considerably lower for each of the three other groups. The results were consistent for basic, instrumental and mobility activities.

CONCLUSION

Among older persons discharged to a SNF after an acute hospitalization, the functional course over 6months was generally poor, with recovery to pre-hospital function observed in only one out of every four cases. Relative to elective major surgery, functional outcomes were worse for non-elective major surgery, critical illness, and other hospitalizations.

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).

Factors Associated with Functional Recovery among Older Intensive Care Unit Survivors

RATIONALE

Most of the 1.4 million older adults who survive the intensive care unit (ICU) annually in the United States face increased disability, but little is known about those who achieve functional recovery.

OBJECTIVES

Our objectives were twofold: to evaluate the incidence and time to recovery of premorbid function within 6 months of a critical illness and to identify independent predictors of functional recovery among older ICU survivors.

METHODS

Potential participants included 754 persons aged 70 years or older who were evaluated monthly in 13 functional activities (1998-2012). The analytic sample included 218 ICU admissions from 186 ICU survivors. Functional recovery was defined as returning to a disability count less than or equal to the pre-ICU disability count within 6 months. Twenty-one potential predictors were evaluated for their associations with recovery.

MEASUREMENTS AND MAIN RESULTS

Functional recovery was observed for 114 (52.3%) of the 218 admissions. In multivariable analysis, higher body mass index (hazard ratio [HR], 1.07; 95% confidence interval [CI], 1.03-1.12) and greater functional self-efficacy (HR, 1.05; 95% CI, 1.02-1.08), a measure of confidence in performing various activities, were associated with recovery, whereas pre-ICU impairment in hearing (HR, 0.38; 95% CI, 0.22-0.66) and vision (HR, 0.59; 95% CI, 0.37-0.95) were associated with a lack of recovery.

CONCLUSIONS

Among older adults who survived an ICU admission with increased disability, pre-ICU hearing and vision impairment were strongly associated with poor functional recovery within 6 months, whereas higher body mass index and functional self-efficacy were associated with recovery. Future research is needed to evaluate whether interventions targeting these factors improve functional outcomes among older ICU survivors.

Comparison of Gait Speed and Peripheral Nerve Function Between Chronic Kidney Disease Patients With and Without Diabetes

OBJECTIVE

To compare overall physical function, including gait speed and peripheral nerve function, between diabetic chronic kidney disease (CKD) patients and nondiabetic CKD patients and to investigate the association between gait speed and peripheral nerve function in CKD patients.

METHODS

Sixty adult CKD patients (35 with and 25 without diabetes), who received maintenance hemodialysis (HD), were included in this study. Demographic data, past medical history, current medical condition and functional data-usual gait speed, vibration perception threshold for the index finger (VPT-F) and the great toe (VPT-T), activity of daily living (ADL) difficulty, and peripheral neuropathy (PN) along with the degree of its severity-were collected and compared between the two groups. Correlations between the severity of PN and the impairment of other functions were identified.

RESULTS

Diabetic CKD patients showed significantly slower gait speed (p=0.029), impaired sensory function (VPT-F, p=0.011; VPT-T, p=0.023), and more frequent and severe PN (number of PN, p<0.001; severity of PN, p<0.001) as compared to those without diabetes. Usual gait speed had a significant negative correlation with the severity of PN (rho=-0.249, p=0.013). By contrast, VPT-F (rho=0.286, p=0.014) and VPT-T (rho=0.332, p=0.035) were positively correlated with the severity of PN. ADL difficulty was comparatively more frequent in the patients with more severe PN (p=0.031).

CONCLUSION

In CKD patients with maintenance HD, their gait speed, sensory functions, and peripheral nerve functions were all significantly impaired when they have diabetes, and the severity of PN was negatively correlated with their gait speed, sensory function, and ADL function. Adverse effects of diabetes impacted physical performance of CKD patients. The physical disability of those patients might be attributable to PN and its severity.

Emergency Department Visits Without Hospitalization Are Associated With Functional Decline in Older Persons

STUDY OBJECTIVE

Among older persons, disability and functional decline are associated with increased mortality, institutionalization, and costs. The aim of the study was to determine whether illnesses and injuries leading to an emergency department (ED) visit but not hospitalization are associated with functional decline among community-living older persons.

METHODS

From a cohort of 754 community-living older persons who have been followed with monthly interviews for up to 14 years, we matched 813 ED visits without hospitalization (ED only) to 813 observations without an ED visit or hospitalization (control). We compared the course of disability during the following 6 months between the 2 matched groups. To establish a frame of reference, we also compared the ED-only group with an unmatched group who were hospitalized after an ED visit (ED-hospitalized). Disability scores (range 0 [lowest] to 13 [highest]) were compared using generalized linear models adjusted for relevant covariates. Admission to a nursing home and mortality were evaluated as secondary outcomes.

RESULTS

The ED-only and control groups were well matched. For both groups, the mean age was 84 years, and 69% were women. The baseline disability scores were 3.4 and 3.6 in the ED-only and control groups, respectively. During the 6-month follow-up period, the ED-only group had significantly higher disability scores than the control group, with an adjusted risk ratio of 1.14 (95% confidence interval [CI] 1.09 to 1.19). Compared with participants in the ED-only group, those who were hospitalized after an ED visit had disability scores that were significantly higher (risk ratio 1.17; 95% CI 1.12 to 1.22). Both nursing home admissions (hazard ratio 3.11; 95% CI 2.05 to 4.72) and mortality (hazard ratio 1.93; 95% CI 1.07 to 3.49) were higher in the ED-only group versus control group during the 6-month follow-up period.

CONCLUSION

Although not as debilitating as an acute hospitalization, illnesses and injuries leading to an ED visit without hospitalization were associated with a clinically meaningful decline in functional status during the following 6 months, suggesting that the period after an ED visit represents a vulnerable time for community-living older persons.

Disability in the Individual ADL, IADL, and Mobility among Older Adults: A Prospective Cohort Study

OBJECTIVES

To examine the risk of disability in 15 individual ADL, IADL, and mobility in older adults by age; and to assess the association of multimorbidity, gender, and education with disability.

DESIGN AND SETTING

A prospective cohort study. The sample included 805 community-dwelling older people aged 60+ living in the Netherlands.

MEASUREMENTS

Disability was assessed using the Katz-15 Index of Independence in Basic Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL) and one mobility item. Disability in any of these activities was defined as the inability to perform the activity without assistance. The risk of disability by age for each individual ADL, IADL, and for mobility was assessed using Generalized mixed models.

RESULTS

Disability in activities as household tasks, traveling, shopping, and continence had the highest risk and increased rapidly with age. The risk traveling disability among people aged 65 with two comorbidities increase from 9% to 37% at age 85. Disability in using the telephone, managing medications, finances, transferring, and toileting, had a very low risk and hardly increased with age. Compared to those without chronic conditions, those with ≥ 3 chronic conditions had a 3 to 5 times higher risk of developing disability. Males had a higher risk of disability in managing medication (P=0.005), and preparing meals (P=0.019), whereas females had a higher risk of disability with traveling (P=0.001). No association between education and disability on the individual ADL, IADL, and mobility was observed.

CONCLUSIONS

Older adults were mostly disabled in physical related activities, whereas disability in more cognitive related activities was less often experienced. The impact of multimorbidity on disability in each activity was substantial, while education was not.

Supplementation of Mussel Peptides Reduces aging Phenotype, Lipid Deposition and Oxidative Stress in D-Galactose-Induce Aging Mice

OBJECTIVES

Aging is associated with glucose and lipid metabolism disorder. We aimed to examine the effects of mussel peptides on protecting against aging by regulating glucose and lipid metabolism.

METHODS

For the aging model, d-galactose (200 mg/kg) was administered subcutaneously to 8-month-old mice for 8 weeks. Mussel peptides (1,000 mg/kg) were simultaneously administered by intragastric gavage. The glucose and lipid metabolism profiles, aging phenotype and peroxisome proliferator-activated receptors (PPARs) expression in the liver and adipose tissue of ICR mice were measured.

RESULTS

D-galactose-treated mice showed pronounced fat deposition and impaired glucose and lipid homeostasis, along with increased oxidative damage and aging. Mussel peptides improved metabolic status by reducing serum glucose and triglyceride levels, insulin resistance and hepatic free fatty acid, as well as enhancing serum high-density lipoprotein (HDL) level and hepatic glycogen content, accompanied with amelioration of aging phenotype and fat deposition. Moreover, mussel peptides ameliorated oxidative stress in aged liver tissues and promoted expression of peroxisome proliferator activated receptors alpha (PPARα) and gamma (PPARγ) in liver and adipose tissues.

CONCLUSIONS

These results indicate that mussel peptides protect against lipid metabolic disorders associated with aging via maintaining oxidative stress homeostasis and elevated expression levels of PPARs.

Cost effectiveness of an intervention focused on reducing bathing disability

The onset of bathing disability among older people is critical for a decline in functioning and has implications for both the individuals’ quality of life and societal costs. The aim of this study was to evaluate long-term cost effectiveness of an intervention targeting bathing disability among older people. For hypothetical cohorts of community-dwelling older people with bathing disability, transitions between states of dependency and death were modelled over 8 years including societal costs. A five-state Markov model based on states of dependency was used to evaluate Quality-adjusted life years (QALYs) and costs from a societal perspective. An intervention group was compared with a no intervention control group. The intervention focused on promoting safe and independent performance of bathing-related tasks. The intervention effect, based on previously published trials, was applied in the model as a 1.4 increased probability of recovery during the first year. Over the full follow-up period, the intervention resulted in QALY gains and reduced societal cost. After 8 years, the intervention resulted in 0.052 QALYs gained and reduced societal costs by €2410 per person. In comparison to the intervention cost, the intervention effect was a more important factor for the magnitude of QALY gains and long-term societal costs. The intervention cost had only minor impact on societal costs. The conclusion was that an intervention targeting bathing disability among older people presents a cost-effective use of resources and leads to both QALY gains and reduced societal costs over 8 years.