Calibrating ADL-IADL scales to improve measurement accuracy and to extend the disability construct into the preclinical range: a systematic review

The role of functioning in predicting nursing home placement or death among older home care patients

OBJECTIVE

There have been few studies predicting institutionalization or death in home care settings. We examined risk factors for nursing home placement (NHP) and death among home care patients.

DESIGN

A prospective one-year follow-up study.

SETTINGS AND SUBJECTS

Persons aged ≥65 years living in Eastern Finland and receiving regular home care services (n = 293).

MAIN OUTCOME MEASURES

Risk factors for NHP or death were investigated using Cox proportional hazards model. Explanatory variables included demographics, health status (Charlson Comorbidity Index, CCI), physical (Timed Up and Go, TUG), and cognitive (Mini-Mental State Examination, MMSE) functioning, Basic and Instrumental Activities of Daily Living (BADL, IADL) and mood (Geriatric Depression Scale, GDS-15).

RESULTS

Of the 293 patients (mean age 82.6 years, 70.6% women), 27 (9.2%) moved to a nursing home and 25 (6.9%) died during the follow-up (mean 350 days). The combined outcome of NHP or death was predicted by BADL (HR 0.73, CI 95% 0.62-0.86), IADL (0.75, 0.65-0.87) MMSE (0.92, 0.87-0.96), and TUG (1.02, 1.01-1.03). NHP alone was predicted by BADL (0.62, 0.50-0.78), IADL (0.57, 0.45-0.73), and MMSE (0.88, 0.82-0.94) and mortality by TUG (1.02, 1.01-1.03).

CONCLUSION

Basic measures of functioning can be used to identify high-risk patients in home care. Decreasing BADL, IADL and MMSE predict NHP and longer TUG-times death within a year.

Transitions in robust and prefrail octogenarians after 1 year: the influence of activities of daily living, social participation, and psychological resilience on the frailty state

BACKGROUND

Knowledge opportunities lie ahead as everyday activities, social participation, and psychological resilience might be important predictors for frailty state transitioning in the oldest old. Therefore, this article aims to examine whether changes in basic-, instrumental-, advanced- activities of daily living (b-, i-, a-ADLs), social participation, and psychological resilience predict both a transition from robustness to prefrailty or frailty and vice versa among community-dwelling octogenarians over a follow-up period of one year.

METHODS

To evaluate worsened and improved frailty transitions after one year in 322 octogenarians (Mage = 83.04 ± 2.78), the variables sex, ADLs (b-ADL-DI, i-ADL-DI, a-ADL-DI as baseline and as difference after 6 months values), the CD-RISC (Connor-Davidson Resilience Scale, as baseline and as difference after 6 months), the social participation variables (total participation score, being a member, total number of memberships, level of social participation, being a board member, volunteering, and formal participation as baseline and as difference after 6 months values), were included in a logistic regression analysis.

RESULTS

Limitations in a-ADLs at baseline (OR: 1.048, 95% confidence interval, 1.010-1.090) and an increment of limitations in a-ADLs after 6 months (OR: 1.044, 95% confidence interval, 1.007-1.085) were predictors to shift from robust to a worsened frailty state after one year follow-up. Additionally, being a woman (OR: 3.682, 95% confidence interval, 1.379-10.139) and social participation, specifically becoming a board member in 6 months (OR: 4.343, 95% confidence interval, 1.082-16.347), were protectors of robustness and thus related to an improved frailty transition after one year.

CONCLUSIONS

Encouraging healthy lifestyle behaviors to help the maintenance of ADLs, possibly leading to more social participation, could be promising in the prevention of frailty.

Associations of baseline glycemic status and its transitions with cognitive and physical functioning decline

OBJECTIVE

Evidence about the decline of cognition and physical function across glycemic status (normoglycemia, prediabetes, and diabetes) is inconsistent. We evaluated longitudinal changes in cognition and physical function according to glycemic status and also different glycemic transitions.

STUDY DESIGN

Population-based cohort study.

METHODS

9307 participants (mean age 59.7 years, 53.7 % women) were included from the China Health and Retirement Longitudinal Study (2011-2018). Global cognition (assessed by orientation, memory, and executive function) and physical function (calculated as the sum of impaired basic and instrumental activities of daily living) were assessed in each wave. The glycemic status was assessed in waves 2011 and 2015. Diabetes was defined as fasting blood glucose ≥7.0 mmol/L, HbA1c ≥6.5 %, self-reported diabetes, or glucose-lowering medication use. Prediabetes was defined as fasting blood glucose 5.6-6.9 mmol/L or an HbA1c of 5.7-6.4 %.

RESULTS

Compared with normoglycemia, baseline diabetes was associated with a faster decline in orientation (-0.018 SD/year, 95%CI -0.032, -0.004) and a faster increase in physical function score (0.082 /year, 95%CI 0.038, 0.126). We did not observe any effect of prediabetes on the changing rate of cognition and physical function. Progression from normoglycemia to diabetes between waves 2011 and 2015 was associated with a significantly faster decline in global cognition, memory, executive function, and physical function compared with stable normoglycemia.

CONCLUSIONS

Baseline diabetes was associated with accelerated decline of cognition and physical function. Associations with prediabetes were not observed, suggesting an important short diagnostic window when diabetes presents de novo.

Health Status and Individual Care Needs of Disabled Elderly at Home in Different Types of Care

For the disabled, paying attention to their health status is the starting point to discovering their survival problems, while meeting their care needs is the end point to solving their survival problems. As the country with the largest number of disabled elderly in the world, how to ensure this group could obtain appropriate home care is a major public health issue facing China. Thus, we conducted a cross-sectional study from October to December 2020 to explore the basic characteristics and health status of disabled elderly in different types of care who are living at home in 37 streets in Shanghai, as well as the individual care needs and its relevance. We observed the significant differences in the number of diagnoses (p = 0.03), smoking (p = 0.009), drinking (p = 0.016), exercise (p = 0.001), activity of daily living (p < 0.0001), and the quality of life (p < 0.0001) across care types. The care needs of the disabled elderly are diversified, of which a vast majority of them have not been fully guaranteed. The urgent need for improving the identification accuracy of care needs of disabled elderly, as well as the development of elaborate and personalized care programs for them, is needed.

Many Paths to Recovery: Comparing Basic Function and Participation in High-Functioning Older Adults After Acute Hospitalization

Function after acute hospitalization is mostly operationalized by Basic Activities of Daily Living (BADL), a limited concept that overshadows a wide range of instrumental, social, and recreational activities, otherwise referred to as participation. Participation is important for patients' health and quality of life after hospitalization. This study focuses on high-functioning older adults, examining functional recovery after hospitalization by comparing BADL assessment with assessment of participation at one and three months following discharge relative to pre-hospitalization. Quantitative data were collected from 72 participants divided into two age groups of hospitalized older adults (age 65-74, n = 38; age ≥75, n = 34), followed by home visits after 1 month and telephone interviews 3 months after discharge. Both groups experienced a significantly greater decline in participation, compared with BADL, which were mostly preserved. A comprehensive assessment of participation better captures functional changes in high-functioning older adults. Early identification of participation withdrawal is crucial for preventing disability.

Assessing patterns and stability of ADL hierarchical scales for functional disability assessment

BACKGROUND AND OBJECTIVES

This study examined the stability over time of activities of daily living (ADL) items in three comparable longitudinal datasets and evaluated ADL loss sequences for older adults in the U.S., South Korea, and Japan.

RESEARCH DESIGN AND METHODS

Data from the U.S. Health and Retirement Study, and its two international sister surveys, were analyzed. Subjects were community-dwelling adults aged 60 and above. For each dataset, Rasch analysis was implemented to determine if the ordering of items remained stable across multiple waves (2006-2014), such that a single ADL hierarchy may be derived from multi-wave data.

RESULTS

Data fitted the Rasch model well. Item calibrations were sufficiently stable across measurement periods in each dataset, reflecting a stable frame of reference. Results were also robust to sample variations. The derived ADL hierarchies based on scaled logit scores revealed that "dressing" and "bathing" were relatively more difficult items for older adults in all study populations.

DISCUSSION AND IMPLICATIONS

Scale stability is essential when exploiting longitudinal data to analyze patterns in ADL disabilities. The consistency in ADL scales across measurement periods supports their use as screening tools and identifying those at risk for transitions in care. Interventions to reduce dependency in bathing and dressing can help improve independent functioning for community-dwelling elderly.

Combined Impact of Positive Screen for Sarcopenia and Frailty on Physical Function, Cognition and Nutrition in the Community Dwelling Older Adult

Background

While sarcopenia and frailty independently contribute to functional impairment and disability, the combined impact resulting from their interplay is unclear. We investigated if functional, physical, cognitive, and nutritional measures were more adversely affected in community-dwelling older adults who were screened positive for both frailty and sarcopenia.

Methods

Using the FRAIL (≥1) and SARC-F (Strength, Assistance with walking, Rising from a chair, Climbing stairs, and Falls) (≥1) scales for screening, we categorized 200 participants (age, 67.9±7.9 years) as combined (both positive, 12.5%), intermediate (either positive, 25.5%), or robust (both negative, 62%).

Results

Comparisons of the three groups showed that the combined group had significantly worse functional ability (Frenchay Activities Index and Modified Barthel Index), physical performance (knee extension, gait speed, and Short Physical Performance Battery score), cognition/mood (Chinese Mini-Mental State Examination [CMMSE] score and Geriatric Depression Scale), and nutrition (Mini Nutritional Assessment [MNA] score) (p<0.05, one-way analysis of variance). Post-hoc comparisons revealed similar findings between the combined and robust groups, except for knee extension and CMMSE scores. Only MNA scores were significantly lower between the intermediate and robust groups.

Conclusion

Functional ability, physical performance, and nutrition were more adversely affected in our study population of community-dwelling older adults who screened positive for both frailty and sarcopenia than in those who screened positive for either or neither, supporting the use of community screening for early detection and intervention for both frailty and sarcopenia as opposed to either alone.

Rasch analysis highlighted relative importance of walking and transferring disabilities among elderly in developing countries

OBJECTIVE

This study examines hierarchical patterns of progression in activities of daily living (ADL) disabilities among older adults in low- and middle-income countries.

STUDY DESIGN AND SETTING

Data from WHO's SAGE survey (2007-2010) on adults aged 60 and above in China, India, Russia, Ghana, Mexico, and South Africa, were analyzed. We used factor analysis and Rasch modelling to develop ADL hierarchies for cross-national comparisons.

RESULTS

Data fitted the Rasch model well and Cronbach's α were 0.80-0.87 across countries. Based on scaled logit scores, "walking" was the most difficult item for older adults in five of the six countries. Older persons in developing countries also found "transferring" to/from beds challenging. "Eating" and "dressing" ranked lower in the hierarchies, thus perceived as easier than other activities. Sequences were most compact for China, Mexico, and India, implying that older adults in these countries who have difficulty "walking" are at high risk of developing the rest of the disabilities.

CONCLUSION

This is the first study that used Rasch analysis to demonstrate that functional loss sequences in various developing countries share certain broad similarities. Interventions targeted at improving walking and transferring activities can help offset certain deficits in independent functioning for community-dwelling elderly in these countries.

Reductions in Muscle Strength and Range of Motion Cause Locomotion Disability via Locomotion-Related Functional Limitation in Japanese Older Adults: A Cross-Sectional Study

Background

Functional issues (impairments, functional limitations, and disabilities) gradually occur with age. Nonetheless, maintaining physical capability may help prevent locomotion disabilities at an older age. The present study aimed to determine whether reductions in muscle strength and range of motion (ROM) cause locomotion disability via locomotion-related functional limitations among healthy older adults.

Methods

Data from a total of 144 participants (61 men, 83 women) were analyzed. To assess locomotion disability, the locomotor domain of the activities of daily living (ADLs) survey from the Ministry of Education, Culture, Sports, Science, and Technology of Japan was used. Muscle strength (grip strength) and two ROMs (hip flexion and knee flexion) were measured. To measure locomotion-related functional limitations, participants underwent a 10 m hurdle walking test and side-step test. Thereafter, path analysis was conducted for testing the hypothetical model. The goodness of fit in the model was assessed using statistical parameters, such as the chi-square value, goodness of fit index (GFI), adjusted goodness of fit index (AGFI), comparative fit index (CFI), and root mean square error of approximation (RMSEA).

Results

The analysis revealed a nonsignificant chi-square value (chi-square = 41.885; p=0.113), as well as high values of GFI (0.944), AGFI (0.904), CFI (0.970), and RMSEA (0.046), indicating that locomotion disability was caused by locomotion-related functional limitations, which were influenced by muscle strength and ROM.

Conclusions

The present study demonstrated that decreased muscle strength and ROM caused locomotion disability via locomotion-related functional limitations. Older adults should participate in physical exercise programs that focus on strengthening muscles and improving ROM to counteract age-related locomotion disability.

More Severe Radiographic Osteoarthritis Is Associated With Increased Improvement in Patients' Health State Following a Total Knee Arthroplasty

BACKGROUND

To assess whether preoperative radiological severity of osteoarthritis (OA) is related to the level of improvement in patients' health state measured 1 year after total knee arthroplasty (TKA).

METHODS

Radiographic severity of OA was graded using the Kellgren-Lawrence (KL) classification. Two independent observers were blinded to patients' outcome scores. Health-related quality of life was measured using EQ-5D-3L preoperatively and at 12-month follow-up. The 5 dimensions of the EQ-5D were converted into a health state index score. The association between KL grade and improvement in health state score was analyzed using multiple linear regression.

RESULTS

Among 156 consecutive patients (68% females, mean age 69 years) who underwent primary TKA, 3 knees (2%) were classified as KL grade 2, 115 as KL grade 3 (74%), and 38 as KL grade 4 (24%). Follow-up rate was 77%. There was substantial intra-rater and inter-rater agreement (Cohen's kappa = 0.80 and 0.79). Most patients (64%) had clinically significant improvement in their health state score 1 year after TKA. However, after adjusting for relevant covariates, patients with severe OA (KL grade 4) were found to have significantly more improvement in their health state score than patients with mild or moderate OA (KL grade 2 or 3, respectively). Separate analysis of the 5 EQ-5D dimensions showed that the KL group differences were most evident in the "usual activities" and "pain/discomfort" dimensions.

CONCLUSION

Patients with severe OA have significantly more improvement in their usual activities and pain/discomfort 1 year after TKA than patients with less severe OA.

Measuring Activity Limitations Within the National Health and Aging Trends Study (NHATS)

BACKGROUND AND OBJECTIVES

To better understand the disablement process among older adults, improved measures of activity limitations are needed. Traditional population-level measures lack the ability to distinguish precise gradations of activity limitation and are unable to detect degrees of differences over a wide range of ability levels. Therefore, we used contemporary measurement methods to improve upon current methodologies for characterizing activity limitations within the National Health and Aging Trends Study (NHATS) .

RESEARCH DESIGN AND METHODS

We used the NHATS Round 1 cohort to assess the feasibility of constructing an Activity Limitations scale using Rasch item response theory methods. Factor analysis was used to develop the scale from a set of existing items in the NHATS Mobility, Self-Care, and Household Activity domains. Psychometric properties of the scale were evaluated and the scale was used to examine change in activity limitations among the sample from 2011 to 2015.

RESULTS

Results supported an 18-item scale (N = 7,609). Rasch infit and outfit statistics were within acceptable range for all items (Cronbach's alpha = 0.95; sample score reliability = 0.83). From 2011 to 2015, 5.88% older adults demonstrated increase in function, 15% showed decrease in function, and 78% of the sample showed no change (did not exceed ± MDC90).

DISCUSSION AND IMPLICATIONS

Findings demonstrate that a unidimensional, interval scale of activity limitations can be constructed using traditional survey measures nested within the NHATS. Results revealed concerns regarding ceiling effects within the current self-report items of activity limitations suggesting future work is needed to expand the range of ability currently represented in the NHATS Activity Limitation items.

Assessing functional status using the IADL-extended scale: results from the HELIAD study

OBJECTIVES

Instrumental activities of daily living (IADL) have been operationalized as exhibiting a greater level of complexity than basic ADL. In the same way, incorporating more advanced ADLs may increase the sensitivity of functional measures to identify cognitive changes that may precede IADL impairment. Towards this direction, the IADL-extended scale (IADL-x) consists of four IADL tasks and five advanced ADLs (leisure time activities).

DESIGN

Retrospective, cross-sectional study.

SETTING

Athens and Larissa, Greece.

PARTICIPANTS

1,864 community-dwelling men and women aged over 64.

MEASUREMENTS

We employed both the IADL-x and IADL scales to assess functional status among all the participants. Diagnoses were assigned dividing the population of our study into three groups: cognitively normal (CN), mild cognitive impairment (MCI) and dementia patients. Neuropsychological evaluation was stratified in five cognitive domains: memory, language, attention-speed, executive functioning and visuospatial perception. Z scores for each cognitive domain as well as a composite z score were constructed. Models were controlled for age, sex, education and depression.

RESULTS

In both IADL-x and IADL scales dementia patients reported the most functional difficulties and CN participants the fewest, with MCI placed in between. When we restricted the analyses to the CN population, lower IADL-x score was associated with worse cognitive performance. This association was not observed when using the original IADL scale.

CONCLUSION

There is strong evidence that the endorsement of more advanced IADLs in functional scales may be useful in detecting cognitive differences within the normal spectrum.

Language equivalence of the modified falls efficacy scale (MFES) among English- and Spanish-speaking older adults: Rasch analysis

BACKGROUND

To investigate item-level measurement properties of the Modified Falls Efficacy (MFES) Scale among English- and Spanish-speaking urban-dwelling older adults as a means to evaluate language equivalence of the tool.

METHODS

Secondary analysis of survey data from 170 English (n = 83) and Spanish (n = 87) speaking older adults who reported to the emergency department of a quaternary medical center in New York City between February 2010 and August 2011. The Rasch rating scale model was used to investigate item statistics and ordering of items, item and person reliability, and model performance of the Modified Falls Efficacy Scale.

RESULTS

The Modified Falls Efficacy Scale, for English- and Spanish-speakers, demonstrated acceptable fit to the Rasch model of a unidimensional measure. While the range of the construct is more limited for the Spanish group, the interval between tasks are much closer, reflecting little to no construct under-representation.

CONCLUSION

There is rationale for continued testing of a unidemsional English- and Spanish-MFES among urban community-dwelling older adults. Large-scale international studies linking the unidemsional MFES to patient outcomes will support the validity of this tool for research and practice.

Comparison of alternative full and brief versions of functional status scales among older adults in China

BACKGROUND

Brief assessments of functional status for community-dwelling older adults are needed given expanded interest in the measurement of functional decline.

METHODS

As part of a 2015 prospective cohort study of older adults aged 60-89 years in Jiangsu Province, China, 1506 participants were randomly assigned to two groups; each group was administered one of two alternative 20-item versions of a scale to assess activities of daily living (ADL) and instrumental activities of daily living (IADL) drawn from multiple commonly-used scales. One version asked if they required help to perform activities (ADL-IADL-HELP-20), while the other version provided additional response options if activities could be done alone but with difficulty (ADL-IADL-DIFFICULTY-20). Item responses to both versions were compared using the binomial test for differences in proportion (with Wald 95% confidence interval [CI]). A brief 9-item scale (ADL-IADL-DIFFICULTY-9) was developed favoring items identified as difficult or requiring help by ≥4%, with low redundancy and/or residual correlations, and with significant correlations with age and other health indicators. We repeated assessment of the measurement properties of the brief scale in two subsequent samples of older adults in Hong Kong in 2016 (aged 70-79 years; n = 404) and 2017 (aged 65-82 years; n = 1854).

RESULTS

Asking if an activity can be done alone but with difficulty increased the proportion of participants reporting restriction on 9 of 20 items, for which 95% CI for difference scores did not overlap with zero; the proportion with at least one limitation increased from 28.6% to 34.2% or an absolute increase of 5.6% (95% CI = 0.9-10.3%), which was a relative increase of 19.6%. The brief ADL-IADL-DIFFICULTY-9 maintained excellent internal consistency (α = 0.93) and had similar ceiling effect (68.1%), invariant item ordering (H trans = .41; medium), and correlations with age and other health measures compared with the 20-item version. The brief scale performed similarly when subsequently administered to older adults in Hong Kong.

CONCLUSIONS

Asking if tasks can be done alone but with difficulty can modestly reduce ceiling effects. It's possible that the length of commonly-used scales can be reduced by over half if researchers are primarily interested in a summed indicator rather than an inventory of specific types of deficits.

Adaptation for Growth Via Learning New Skills as a Means to Long-Term Functional Independence in Older Adulthood: Insights From Emerging Adulthood

Maintenance of functional independence, or the ability to perform daily tasks independently, is a hallmark of successful aging. Healthy older adults are considered functionally independent if they pass a short survey consisting of relatively simple daily activities, including grocery shopping and managing finances. We argue that aging research often has overlooked an important factor for long-term functional independence in a dynamic environment: adaptation for growth via learning new skills. Previous research has focused primarily on compensation and mitigating decline rather than growth. Given that adaptation for growth is at the core of intelligence, resilience, and neuroplasticity, we suggest that functional independence research with older adults could integrate adaptation for growth into the construct, following research on adolescent autonomy and emerging adulthood. After briefly reviewing research on functional independence and compensation in older adulthood, we offer suggestions to push forward gerontological research linking adaptation for growth and functional independence.

Development of the Central Africa Daily Functioning Interference Scale for Dementia Diagnosis in Older Adults: The EPIDEMCA Study

BACKGROUND

There are a few validated tools capable of assessing the dimensions essential for the diagnosis of dementia and cognitive disorders in sub-Saharan Africa.

OBJECTIVES

Our aim was to develop an adapted tool, the Central African - Daily Functioning Interference (DFI) scale.

METHODS

An initial 16-item scale of activity limitations and participation restrictions was completed by 301 participants with low cognitive performances to assess their level of DFI. A psychometric evaluation was performed using Item Response Theory.

RESULTS

A unidimensional 10-item scale emerged with a reasonable coverage of DFI (thresholds range: -1.067 to 1.587) with good item discrimination properties (1.397-4.076) and a high reliability (Cronbach's al pha = 0.92). The cutoff for detecting 96% of those with dementia was with a latent score ≥0.035 that corresponds to the LAUNDRY limitation.

CONCLUSIONS

These results provide valuable support for the reliability and internal validity of an operational 10-item scale for DFI assessment used in Central Africa for the diagnosis of dementia in the elderly.

Disability incidence and functional decline among older adults with major chronic diseases

Background

More than 80% of elderly Americans have at least one chronic disease. While past studies have shown that hierarchical patterns of functional loss may differ by gender and institutional settings, little is known about whether such patterns differ in relation to chronic health condition. The aim of this study is to investigate the pattern of functional loss among older adults with major chronic illnesses, and to compare their onset and ordering of incident ADL disability with those of persons without such conditions.

Methods

We use a nationally representative sample of persons aged 80+ from the 1998–2014 Asset and Health Dynamics of the Oldest Old survey. The group with major noncommunicable diseases (including cardiovascular disease, cancer, chronic respiratory disease, and diabetes) comprises 3,514,052 subjects, while the comparison group comprises 1,073,263 subjects. Self-reports of having difficulty with six distinct ADLs are used to estimate disability incidence rate. Nonparametric statistical methods are used to derive median onset ages and ADL loss sequence separately for each group.

Results

Older adults with major chronic diseases have higher rates of incident disability across all ADL items. Estimated median onset ages of ADL disabilities for the full sample range from 91.5 to 95.6. Disability occurs earlier for chronically ill persons (onset ages 91.1–95.0) than for those in the comparison group (onset ages 93.5–98.1). Among those with major chronic diseases, the ADL loss sequence ordered by median ages of disability onset is bathing, walking, dressing, toileting, transferring and eating. The activities are also distinctly separated into an early-loss cluster and a late-loss cluster. Although the loss sequence derived for the comparison group is largely similar, disability progression for those with major chronic diseases is compressed within a shorter timeframe and the timing gaps between adjacent disabilities are smaller.

Conclusions

Older Americans with major noncommunicable diseases face an earlier and steeper slope of functional decline. Chronic care delivery programs should adapt to dynamic changes in older patients’ functional status. Health interventions to help patients delay disability onset and optimize functional autonomy within emerging models of chronic care should especially target early-loss activities such as bathing, dressing, and walking.

The structure and predictive value of intrinsic capacity in a longitudinal study of ageing

OBJECTIVES

To assess the validity of the WHO concept of intrinsic capacity in a longitudinal study of ageing; to identify whether this overall measure disaggregated into biologically plausible and clinically useful subdomains; and to assess whether total capacity predicted subsequent care dependence.

DESIGN

Structural equation modelling of biomarkers and self-reported measures in the English Longitudinal Study of Ageing including exploratory factor analysis, exploratory bi-factor analysis and confirmatory factor analysis. Longitudinal mediation and moderation analysis of incident care dependence.

SETTINGS

Community, United Kingdom.

PARTICIPANTS

2560 eligible participants aged over 60 years.

MAIN OUTCOME MEASURES

Activities of daily living (ADL) and instrumental activities of daily living (IADL).

RESULTS

One general factor (intrinsic capacity) and five subfactors emerged: locomotor, cognitive; psychological; sensory; and 'vitality'. This structure is consistent with biological theory and the model had a good fit for the data (χ²=71.2 (df=39)). The summary score of intrinsic capacity and specific subfactors showed good construct validity. In a causal path model examining incident loss of ADL and IADL, intrinsic capacity had a direct relationship with the outcome-root mean square error of approximation (RMSEA)=0.02 (90% CI 0.001 to 0.05) and RMSEA=0.008 (90% CI0.001 to 0.03) respectively-and was a strong mediator for the effect of age, sex, wealth and education. Multimorbidity had an independent direct relationship with incident loss of ADLs but not IADLs, and also operated through intrinsic capacity. More of the indirect effect of personal characteristics on incident loss of ADLs and IADLs was mediated by intrinsic capacity than multimorbidity.

CONCLUSIONS

The WHO construct of intrinsic capacity appears to provide valuable predictive information on an individual's subsequent functioning, even after accounting for the number of multimorbidities. The proposed general factor and subdomain structure may contribute to a transformative paradigm for future research and clinical practice.

The Historical Progression From ADL Scrutiny to IADL to Advanced ADL: Assessing Functional Status in the Earliest Stages of Dementia

Background

Decrements in instrumental activities (IADL) have been observed in the prodromal phase of dementia. Given the long predementia stage in neurodegenerative diseases, it has been proposed that subtle functional changes may precede clinical IADL impairment. Incorporating more challenging advanced ADLs (eg, volunteer work) into the assessment process may increase the sensitivity of functional measures, thus expanding the window for monitoring or interventions.

Methods

Longitudinal cohort study was used (follow-ups, 18-24 month), with subjects aged 60 and older (n = 3,635). To elucidate the relationship between cognitive ability and functional status we employed an IADL scale with an extended range (ADL-extended; includes IADL but also more challenging advanced ADLs) that meets item response theory properties of dimensionality, monotonicity, and item hierarchy. Procedures involved (a) a dynamic change model employed to inspect the temporal relationship between ADL-extended and cognitive status and (b) Cox proportional hazards to assess the risk of incident dementia based on ADL-extended scores.

Results

Growth curve modeling: baseline ADL-extended was significantly associated with all four cognitive domains investigated. Worse baseline ADL-extended was associated with more rapid declines in speed/executive function, and worse baseline memory was associated with more rapid declines in ADL-extended; a concurrent association was found for language and ADL-extended. Cox model: the risk of dementia was decreased for each additional ADL-extended item endorsed (hazard ratio [HR], 0.85; 95% confidence interval = 0.81-0.90).

Conclusions

An increased risk of dementia could be observed in the ADL-extended items, which reflects an area of the functional continuum beyond IADL competencies.

Activities of daily living in older community-dwelling persons: a systematic review of psychometric properties of instruments

BACKGROUND

Activities of daily living (ADL) are often used as predictors of health and function in older persons. This systematic review is part of a series initiated by the European Network for Action on Ageing and Physical Activity (EUNAAPA).

AIM

To assess psychometric properties of ADL instruments for use in older populations.

METHODS

Electronic databases (Medline, EMBASE, AMED, Psycinfo, CINAHL) were searched, using MeSH terms and relevant keywords. Studies, published in English, were included if they evaluated one or more psychometric properties of ADL instruments in community-dwelling older persons aged 60 years and older. Combination scales with IADL were excluded. This systematic review adhered to a pre-specified protocol regarding reliability, validity, and responsiveness.

RESULTS

In total, 140 articles describing more than 50 different ADL instruments were included. Ten instruments which were applied in minimally three different articles of good quality (clear descriptions and adequate design according to the protocol), were evaluated for reliability, validity and responsiveness; each received a summary score. The four instruments with the highest scores were the Functional Autonomy Measurement System (SMAF), 5-items Katz list (although content and wording are often inconsistent across studies), Functional Independence and Difficulty Scale (FIDS) and the Barthel Index.

DISCUSSION

Critical reflection is essential to avoid unnecessary modifications and use of instruments that have not been documented to be valid or reliable.

CONCLUSION

Based on this systematic review, we recommend the SMAF, 5-item Katz, FIDS and Barthel index as ADL measures for research and care practice in older populations.

Convergent and concurrent validity of a report- versus performance-based evaluation of everyday functioning in the diagnosis of cognitive disorders in a geriatric population

ABSTRACTBackground:Several methods have been developed to evaluate activities of daily living (ADLs) in mild cognitive impairment (MCI) and mild dementia. This study evaluated the convergent and concurrent validity between (1) two report-based methods (the advanced (a)- and instrumental (i)-ADL tools) and (2) a performance-based method (the Naturalistic Action Test (NAT)) to check if their ability to differentiate between cognitively healthy comparisons (HCs), persons with MCI, and persons with mild Alzheimer's disease (AD) are comparable to each other.

METHOD

This was a cross-sectional study, undertaken in a geriatric day hospital. The participants comprised community-dwelling HCs (n = 21, median age 78.0 years, 61.9% female), MCI (n = 20, median age 79.5 years, 55.0% female), and AD (n = 20, median age 80.0 years, 85.0% female) adults. A diagnostic procedure for neurocognitive disorders was employed. In addition, the a- and i-ADL tools and the NAT were administered separately by blinded raters.

RESULTS

The NAT and both the a- and i-ADL tools showed significant differences between HCs, MCI, and AD participants. Convergent validity showed moderate to strong significant correlations between the NAT, and a- and i-ADL tools (range -0.583 to -0.663; p &lt; 0.01). Concurrent validity showed that the NAT (AUC 0.809-1.000) and the a- and i-ADL tools (AUC 0.739-0.964) presented comparable discriminatory accuracy (p = 0.0588).

CONCLUSIONS

In contrast to prior studies comparing report-based and performance-based methods of assessing ADL, this study indicates that the NAT and the a- and i-ADL tools have strong convergent and concurrent validity, and appear to have similar discriminatory power in differentiating between HCs, MCI, and AD.

Disability subtypes and mortality rates in older adults: A longitudinal population-based study (NEDICES)

OBJECTIVE

We investigated the mortality rates of three subtypes of disability and their specific explanatory factors in older adults.

METHODS

Our data come from NEDICES, a population-based longitudinal cohort study of Spanish older adults. We examined 3816 participants without dementia who completed the Pfeffer's Functional Activities Questionnaire (FAQ) and an assessment of self-perceived functional limitations (SFL) associated with health conditions. Subjects were classified into mutually exclusive subtypes of disability: subtype 1 (SFL), subtype 2 (impaired FAQ), and subtype 3 (impaired FAQ plus SFL). Factors related to all disability subtypes were analyzed using a multinomial logistic regression (MLR), whereas Cox regression (CR) models adjusted by covariates were applied to compare survival rates between groups at the 5-year follow up.

RESULTS

The CR models indicated that SFL and FAQ scores were associated with higher risk of mortality at 5-years. After stratifying by subtypes of disability, mortality was significantly higher in subtype 3 than in subtypes 1 and 2. All models were consistent after adjusting by different covariates. The MLR showed that subtype 1 was specifically associated with the number of comorbidities, whereas subtype 2 was associated with lower MMSE scores depression and living in nursing homes.

CONCLUSIONS

Our results show that the combination of impaired FAQ plus SFL have an increased differential predictive utility for mortality than approaches based on unique measures. They also indicate that both measures of disability are associated with different explanatory factors.

Establishing dimensionality of sexual behaviours in patients with regional brain dysfunction

OBJECTIVE

To develop a validated, caregiver-based measurement scale to assess sexual changes across several domains in a sample of 86 patients with penetrating traumatic brain injury (TBI) and 65 patients with neurodegeneration due to frontotemporal dementia and corticobasal syndrome.

METHODS

A new measure, the Sexual Symptoms in Neurological Illness and Injury Questionnaire (SNIQ), was constructed. Dimensionality, monotonicity, item discrimination power, and scalability were evaluated using nonparametric Mokken item response theory (IRT) methodology.

RESULTS

Three primary domains were established. The domains presented with sufficient reliability (rho .70 to .80), while meeting the Mokken IRT criteria of medium scalability. The domains were labeled 'Prosocial sexual behaviour' (H = .42), 'Sexual interest' (H = .50), and 'Inappropriate sexual behaviour' (H = .41). A fourth dimension emerged, 'Detachment' (H = .47), but with very few items.

CONCLUSIONS

Construct validity was established for groups of items pertaining to three unique aspects of sexuality. These findings support further use of the SNIQ in assessing and researching sexual behaviours in patients with dementia and brain injury.

Frailty in elderly ICU patients in Greece: a prospective, observational study

Background

Of particular interest is the study of frailty syndrome in older patients in recent years. This syndrome is characterized by weight loss and muscle mass, a change in eating habits, movement and endurance, and a decline in cognitive function. The purpose of the study was the prevalence of frailty syndrome in subjects aged 65 years who were hospitalized in an intensive care unit (ICU) in Greece.

Methods

This is a prospective, observational study. The study sample consisted of families or carers of 36 patients over 65 years of age. The study was conducted in a General Hospital in Greece, over a period of 1 year. The Clinical Frailty Scale (CFS) and the 5 criterions frailty phenotype were used. In addition, the severity of the patients with the APACHE II, SAPS II and SOFA scales was assessed. For the analysis of the data, the SPSS 19 for windows statistical package was used and more specifically descriptive statistics and correlations with parametric methods were performed.

Results

Thirty-six severely ill patients aged 65 years and over (22 women, 14 men) were studied. 25% of the patients had a positive frailty phenotype, 44% were at an early stage, while 30.6% had a frailty negative phenotype. A significant correlation between CFS and APACHE (P=0.041), age (P=0.033), sex (P=0.049) and ADL mobility index (P=0.001) was found to be significant. Concerning mortality, 36.1% of patients died in ICU, 11.1% died within the next 6 months and 38.9% were alive.

Conclusions

The findings of the study highlighted the onset of frailty syndrome in ICU patients. The objective assessment of the frailty syndrome of the seriously ill patient as well as the prognostic markers provides a clearer picture of its out-of-hospital condition and contributes to the collection of information on the outcomes of the in-hospital treatment.

Disability Experience and Measurement

Top themes of international research on disability in the past three decades are discussed: disability dynamics, buffers and barriers for disability, disability trends, and disability among very old persons. Each theme is highlighted by research examples. Turning to measurement, I discuss traditional measures of disability, new longer and shorter ones, and composites like disability-free life expectancy, noting their merits. Contemporary models of disability are presented, ranging from visual images to formal theories. The article ends on how scientists can facilitate movement of disability science into health care practice and policy.

Development of a Computerized Adaptive Testing System of the Functional Assessment of Stroke

OBJECTIVE

To develop a computerized adaptive testing system of the Functional Assessment of Stroke (CAT-FAS) to assess upper- and lower-extremity (UE/LE) motor function, postural control, and basic activities of daily living with optimal efficiency and without sacrificing psychometric properties in patients with stroke.

DESIGN

Simulation study.

SETTING

One rehabilitation unit in a medical center.

PARTICIPANTS

Patients with subacute stroke (N=301; mean age, 67.3±10.9; intracranial infarction, 74.5%).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The UE and LE subscales of the Fugl-Meyer Assessment, Postural Assessment Scale for Stroke Patients, and Barthel Index.

RESULTS

The CAT-FAS adopting the optimal stopping rule (limited reliability increase of <.010) had good Rasch reliability across the 4 domains (.88-.93) and needed few items for the whole administration (8.5 items on average). The concurrent validity (CAT-FAS vs original tests, Pearson r=.91-.95) and responsiveness (standardized response mean, .65-.76) of the CAT-FAS were good in patients with stroke.

CONCLUSIONS

We developed the CAT-FAS, and our results support that the CAT-FAS has sufficient efficiency, reliability, concurrent validity, and responsiveness in patients with stroke. The CAT-FAS can be used to simultaneously assess patients' functions of UE, LE, postural control, and basic activities of daily living using, on average, no more than 10 items; this efficiency is useful in reducing the assessment burdens for both clinicians and patients.

E pluribus unum: Harmonization of physical functioning across intervention studies of middle-aged and older adults

Common scales for physical functioning are not directly comparable without harmonization techniques, complicating attempts to pool data across studies. Our aim was to provide a standardized metric for physical functioning in adults based on basic and instrumental activities of daily living scaled to NIH PROMIS norms. We provide an item bank to compare the difficulty of various physical functioning activities. We used item response theory methods to place 232 basic and instrumental activities of daily living questions, administered across eight intervention studies of middle-aged and older adults (N = 2,556), on a common metric. We compared the scale’s precision to an average z-score of items and evaluated criterion validity based on objective measures of physical functioning and Fried’s frailty criteria. Model-estimated item thresholds were widely distributed across the range of physical functioning. From test information plots, the lowest precision in each dataset was 0.80. Using power calculations, the sample size needed to detect 25% physical functional decline with 80% power based on the physical functioning factor was less than half of what would be needed using an average z-score. The physical functioning factor correlated in expected directions with objective measurements from the Timed Up and Go task, tandem balance, gait speed, chair stands, grip strength, and frailty status. Item-level harmonization enables direct comparison of physical functioning measures across existing and potentially future studies and across levels of function using a nationally representative metric. We identified key thresholds of physical functioning items in an item bank to facilitate clinical and epidemiologic decision-making.

Refining 3 Measures to Construct an Efficient Functional Assessment of Stroke

Background and Purpose—

The Fugl-Meyer Assessment motor scale, Postural Assessment Scale for Stroke patients, and Barthel Index are widely used to assess patients’ upper extremity and lower extremity motor function, balance, and basic activities of daily living after stroke, respectively. However, these 3 measures (72 items) require a great amount of time for assessment. Therefore, we aimed to develop an efficient test, the Functional Assessment of Stroke (FAS).

Methods—

The FAS was constructed from 4 short-form tests of the Fugl-Meyer Assessment-upper extremity, Fugl-Meyer Assessment-lower extremity, Postural Assessment Scale for Stroke patients, and Barthel Index based on the results of Rasch analyses and the items’ content. We examined the psychometric properties of the FAS, including Rasch reliability, concurrent validity, convergent validity, known-group validity, and responsiveness.

Results—

The FAS contained 29 items (10, 6, 8, and 5 items for the 4 short-form tests, respectively). The FAS demonstrated high Rasch reliability (0.92–0.94), concurrent validity ( r =0.90–0.97 with the original tests), convergent validity ( r =0.62–0.94 with the 5-scale Fugl-Meyer Assessment), and known-group validity (significant difference in the FAS scores among 3 groups of disability levels; P <0.001). In addition, the responsiveness of the FAS (standardized response mean=0.55–1.93) was similar or significantly superior to those of the original tests (standardized response mean=0.46–1.39).

Conclusions—

The FAS contains 29 items and has sufficient Rasch reliability, validities, and responsiveness. These findings support that the FAS is efficient for reliably and validly assessing upper extremity/lower extremity motor function, balance, and basic activities of daily living and for sensitively detecting change in those functions in patients with stroke.

Disentangling the complex relation of disability and depressive symptoms in old age - findings of a multicenter prospective cohort study in Germany

BACKGROUND

Most of the previous studies attempted to disentangle the relationship between disability and depressive symptoms were limited to observation periods of only few years. Moreover, evidence is missing regarding the complex co-occurrence of disability and depressive symptoms in old age in Germany. In order to close the research gap, we aimed at disentangling the complex co-occurrence of disability and depressive symptoms in old age in Germany over a longer time frame.

METHODS

Based on data from a representative survey of the German general population aged 75 years and older, the course of disability as well as depressive symptoms was observed every 1.5 years over six waves. While disability was quantified by the Lawton and Brody Instrumental Activities of Daily Living scale, the Geriatric Depression Scale was used to measure depressive symptoms. Taking into account the complex co-occurrence of depressive symptoms and disability, a panel vector autoregressive model was used. By taking the first differences, unobserved heterogeneity was taken into account.

RESULTS

In the total sample and in both sexes, we revealed a robust positive association between an initial change in depressive symptoms and subsequent changes in disability. No robust association between an initial change in disability and a subsequent change in depressive symptoms was detected.

CONCLUSION

Our findings highlight the importance of changes in depressive symptoms for future changes in disability in old age.

Identifying longitudinal sustainable hierarchies in activities of daily living

Activities of daily living serve as an indicator of progression in disability and rehabilitation. It is know that some of the measurement scales used show hierarchical properties indicating that activities of daily living are lost and gained in a consistent pattern. Few studies have investigated the extent to which these patterns are sustained across time and across a range of disability. The study aimed to investigate the hierarchical properties of the activity of daily living items in the ValGraf functional ability scale, to establish if there is a hierarchy of items in the scale and to study the sustainability of the hierarchy over time. Secondary analysis of a retrospective database from 13,113 people over 65 years in 105 nursing homes in northern Italy, between 2008 and 2013 was conducted. Data were gathered 6-monthly and analysed using Mokken scaling to identify a hierarchy of items in the scale and if this was sustainable over time. A sustainable hierarchy of items was observed running in difficulty from urinary incontinence to feeding. The hierarchical structure of the activities of daily living observed in the present study is stable over time meaning that changes in total score for these items can be compared meaningfully across time.

Early diagnosis of mild cognitive impairment and mild dementia through basic and instrumental activities of daily living: Development of a new evaluation tool

BACKGROUND

Assessment of activities of daily living (ADL) is paramount to determine impairment in everyday functioning and to ensure accurate early diagnosis of neurocognitive disorders. Unfortunately, most common ADL tools are limited in their use in a diagnostic process. This study developed a new evaluation by adopting the items of the Katz Index (basic [b-] ADL) and Lawton Scale (instrumental [i-] ADL), defining them with the terminology of the International Classification of Human Functioning, Disability and Health (ICF), adding the scoring system of the ICF, and adding the possibility to identify underlying causes of limitations in ADL.

METHODS AND FINDINGS

The construct validity, interrater reliability, and discriminative validity of this new evaluation were determined. From 2015 until 2016, older persons (65-93 y) with normal cognitive ageing (healthy comparison [HC]) (n = 79), mild cognitive impairment (MCI) (n = 73), and Alzheimer disease (AD) (n = 71) underwent a diagnostic procedure for neurocognitive disorders at the geriatric day hospital of the Universitair Ziekenhuis Brussel (Brussels, Belgium). Additionally, the ICF-based evaluation for b- and i-ADL was carried out. A global disability index (DI), a cognitive DI (CDI), and a physical DI (PDI) were calculated. The i-ADL-CDI showed high accuracy and higher discriminative power than the Lawton Scale in differentiating HC and MCI (area under the curve [AUC] = 0.895, 95% CI .840-.950, p = .002), MCI and AD (AUC = 0.805, 95% CI .805-.734, p = .010), and HC and AD (AUC = 0.990, 95% CI .978-1.000, p < .001). The b-ADL-DI showed significantly better discriminative accuracy than the Katz Index in differentiating HC and AD (AUC = 0.828, 95% CI .759-.897, p = .039). This study was conducted in a clinically relevant sample. However, heterogeneity between HC, MCI, and AD and the use of different methods of reporting ADL might limit this study.

CONCLUSIONS

This evaluation of b- and i-ADL can contribute to the diagnostic differentiation between cognitively healthy ageing and neurocognitive disorders in older age. This evaluation provides more clarity and nuance in assessing everyday functioning by using an ICF-based terminology and scoring system. Also, the possibility to take underlying causes of limitations into account seems to be valuable since it is crucial to determine the extent to which cognitive decline is responsible for functional impairment in diagnosing neurocognitive disorders. Though further prospective validation is still required, the i-ADL-CDI might be useful in clinical practice since it identifies impairment in i-ADL exclusively because of cognitive limitations.

Aging With Disability for Midlife and Older Adults

This analysis brings “aging with disability” into middle and older ages. We study U.S. adults ages 51+ and ages 65+ with persistent disability (physical, household management, personal care; physical limitations, instrumental activities of daily living [IADLs], activities of daily living [ADLs]), using Health and Retirement Study data. Two complementary approaches are used to identify persons with persistent disability, one based directly on observed data and the other on latent classes. Both approaches show that persistent disability is more common for persons ages 65+ than ages 51+ and more common for physical limitations than IADLs and ADLs. People with persistent disability have social and health disadvantages compared to people with other longitudinal experiences. The analysis integrates two research avenues, aging with disability and disability trajectories. It gives empirical heft to government efforts to make aging with disability an age-free (all ages) rather than age-targeted (children and youths) perspective.

A cross-sectional study of male and female C57BL/6Nia mice suggests lifespan and healthspan are not necessarily correlated

Lifespan provides a discrete metric that is intuitively appealing and the assumption has been that healthspan is extended concomitant with lifespan. Medicine has been more successful at extending life than preserving health during aging. Interventions that extend lifespan in model organisms do not always result in a corresponding increase in healthspan, suggesting that lifespan and healthspan may be uncoupled. To understand how interventions that extend life affect healthspan, we need measures that distinguish between young and old animals. Here we measured age-related changes in healthspan in male and female C57BL/6JNia mice assessed at 4 distinct ages (4 months, 20 months, 28 months and 32 months). Correlations between health parameters and age varied. Some parameters show consistent patterns with age across studies and in both sexes, others changed in one sex only and others showed no significant differences in mice of different ages. Few correlations existed among health assays, suggesting that physiological function in domains we assessed change independently in aging mice. With one exception, health parameters were not significantly associated with an increased probability of premature death. Our results show the need for more robust measures of murine health and suggest a potential disconnect between health and lifespan in mice.

Measurement of the severity of disability in community-dwelling adults and older adults: interval-level measures for accurate comparisons in large survey data sets

OBJECTIVES

To (1) create a single metric of disability using Rasch modelling to be used for comparing disability severity levels across groups and countries, (2) test whether the interval-level measures were invariant across countries, sociodemographic and health variables and (3) examine the gains in precision using interval-level measures relative to ordinal scores when discriminating between groups known to differ in disability.

DESIGN

Cross-sectional, population-based study.

SETTING/PARTICIPANTS

Data were drawn from the Survey of Health, Ageing and Retirement in Europe (SHARE), including comparable data across 16 countries and involving 58 489 community-dwelling adults aged 50+.

MAIN OUTCOME MEASURES

A single metric of disability composed of self-care and instrumental activities of daily living (IADLs) and functional limitations. We examined the construct validity through the fit to the Rasch model and the know-groups method. Reliability was examined using person separation reliability.

RESULTS

The single metric fulfilled the requirements of a strong hierarchical scale; was able to separate persons with different levels of disability; demonstrated invariance of the item hierarchy across countries; and was unbiased by age, gender and different health conditions. However, we found a blurred hierarchy of ADL and IADL tasks. Rasch-based measures yielded gains in relative precision (11-116%) in discriminating between groups with different medical conditions.

CONCLUSIONS

Equal-interval measures, with person-invariance and item-invariance properties, provide epidemiologists and researchers with the opportunity to gain better insight into the hierarchical structure of functional disability, and yield more reliable and accurate estimates of disability across groups and countries. Interval-level measures of disability allow parametric statistical analysis to confidently examine the relationship between disability and continuous measures so frequent in health sciences (eg, cholesterol, blood pressure, C reactive protein).

Locomotive Syndrome: Definition and Management

Locomotive syndrome is a condition of reduced mobility due to impairment of locomotive organs. Since upright bipedal walking involves minutely controlled movement patterns, impairment of any aspect of the locomotive organs has the potential to adversely affect it. In addition to trauma, chronic diseases of the locomotive organs, which progress with repeated bouts of acute exacerbations, are common causes of the locomotive syndrome. In Japan's super-aging society, many people are likely to experience locomotive syndrome in the later part of their lives. Exercise intervention is effective in improving motor function, but because the subjects are elderly people with significant degenerative diseases of the locomotor organs, caution should be taken in choosing the type and intensity of exercise. The present review discusses the definition, current burden, diagnosis and interventions pertaining to the locomotive syndrome. The concept and measures are spreading throughout Japan as one of the national health policy targets.

Rasch analysis reveals comparative analyses of activities of daily living/instrumental activities of daily living summary scores from different residential settings is inappropriate

OBJECTIVES

To internally validate a 15-item dichotomous activities of daily living (ADL) and instrumental activities of daily living (IADL) index.

STUDY DESIGN AND SETTING

Data were extracted from The Older Persons and Informal Caregivers Survey Minimum DataSet (TOPICS-MDS). Using Rasch modeling, six aspects of the ADL/IADL scale were assessed: (1) overall fit, (2) internal consistency, (3) individual item and person fit, (4) local dependency, (5) targeting, and (6) differential item functioning (DIF) (RUMM 2030). All analyses were stratified by living situation [community-dwelling (n = 21,926) or residential care facility (n = 2,458)].

RESULTS

In both settings, "eating" was the easiest activity on the scale and "performing household tasks" was the most difficult activity. However, based on the location on the logit scale, the level of difficulty for certain items varied between residential settings, suggesting summary scores are not equivalent between these settings. DIF by gender and age group was observed for several items, indicating potential measurement bias in the scale.

CONCLUSION

Unless adjustments are undertaken, ADL/IADL summary scores retrieved from older persons residing in the community or residential care facilities should not be directly compared. This 15-item scale is poorly targeted for a community-dwelling older population, underscoring the need for items with improved discriminative ability.

Gait Speed Predicts Incident Disability: A Pooled Analysis

BACKGROUND

Functional independence with aging is an important goal for individuals and society. Simple prognostic indicators can inform health promotion and care planning, but evidence is limited by heterogeneity in measures of function.

METHODS

We performed a pooled analysis of data from seven studies of 27,220 community-dwelling older adults aged 65 or older with baseline gait speed, followed for disability and mortality. Outcomes were incident inability or dependence on another person in bathing or dressing; and difficulty walking ¼ - ½ mile or climbing 10 steps within 3 years.

RESULTS

Participants with faster baseline gait had lower rates of incident disability. In subgroups (defined by 0.2 m/s-wide intervals from <0.4 to ≥ 1.4 m/s) with increasingly greater gait speed, 3-year rates of bathing or dressing dependence trended from 10% to 1% in men, and from 15% to 1% in women, while mobility difficulty trended from 47% to 4% in men and 40% to 6% in women. The age-adjusted relative risk ratio per 0.1 m/s greater speed for bathing or dressing dependence in men was 0.68 (0.57-0.81) and in women: 0.74 (0.66-0.82); for mobility difficulty, men: 0.75 (0.68-0.82), women: 0.73 (0.67-0.80). Results were similar for combined disability and mortality. Effects were largely consistent across subgroups based on age, gender, race, body mass index, prior hospitalization, and selected chronic conditions. In the presence of multiple other risk factors for disability, gait speed significantly increased the area under the receiver operator characteristic curve.

CONCLUSION

In older adults, gait speed predicts 3 year incidence of bathing or dressing dependence, mobility difficulty, and a composite outcome of disability and mortality.

Specific cognitive functions and depressive symptoms as predictors of activities of daily living in older adults with heterogeneous cognitive backgrounds

Cognitive functioning influences activities of daily living (ADL). However, studies reporting the association between ADL and neuropsychological performance show inconsistent results regarding what specific cognitive domains are related to each specific functional domains. Additionally, whether depressive symptoms are associated with a worse functional performance in older adults is still under explored. We investigated if specific cognitive domains and depressive symptoms would affect different aspects of ADL. Participants were 274 older adults (96 normal aging participants, 85 patients with mild cognitive impairment, and 93 patients probable with mild Alzheimer's disease dementia) with low formal education (∼4 years). Measures of ADL included three complexity levels: Self-care, Instrumental-Domestic, and Instrumental-Complex. The specific cognitive functions were evaluated through a factorial strategy resulting in four cognitive domains: Executive Functions, Language/Semantic Memory, Episodic Memory, and Visuospatial Abilities. The Geriatric Depression Scale measured depressive symptoms. Multiple linear regression analysis showed executive functions and episodic memory as significant predictors of Instrumental-Domestic ADL, and executive functions, episodic memory and language/semantic memory as predictors of Instrumental-Complex ADL (22 and 28% of explained variance, respectively). Ordinal regression analysis showed the influence of specific cognitive functions and depressive symptoms on each one of the instrumental ADL. We observed a heterogeneous pattern of association with explained variance ranging from 22 to 38%. Different instrumental ADL had specific cognitive predictors and depressive symptoms were predictive of ADL involving social contact. Our results suggest a specific pattern of influence depending on the specific instrumental daily living activity.

[Standardization of the Test Your Memory and evaluation of their concordance with the outcome of the psychometric examination]

OBJECTIVE

To explore the relationship between scores on the Test Your Memory (TYM) battery and findings from a more exhaustive neurocognitive assessment.

METHODS

The TYM and fourteen psychometric tests were administered to 84 subjects aged 50 or older who attended an outpatient neurology clinic due to cognitive symptoms. Each patient's cognitive state was determined independently from his/her score on the TYM (CDR 0, n=25; CDR 0.5, n=45; CDR 1, n=14). We analysed concurrent validity of TYM scores and results from the psychometric tests, as well as the degree of concordance between the two types of measurement, by contrasting normalised data from each instrument.

RESULTS

Although the intraclass correlation coefficient was 0.67 (confidence interval 95%, 0.53-0.77), analysis of the Bland-Altman plot and the curve on the survival-agreement plot (Luiz et al. method) demonstrates that the individual distances between the two methods exhibit excessive dispersion from a clinical viewpoint. TYM-based predictions of the mean z-score on psychometric tests differed substantially from real results in 30% of the subjects. Concordance of 95% can only be achieved by accepting absolute inter-instrument differences of up to 0.87 as identical values. Furthermore, the TYM underestimates cognitive performance for low values and overestimates it for high values.

CONCLUSIONS

The TYM is a cognitive screening test which should not be used to predict results on psychometric tests or to detect cognitive changes in clinical trials.

Hierarchical nature of activities of daily living in the Spanish Disability Survey

Many studies have addressed the issue of dimensionality in activities of daily living (ADL) and its hierarchy, with contradictory results. This paper aims to study the unidimensional structure and the hierarchy of ADL in the Spanish Disability Survey. We analysed a sample of 8381 people aged 65 and over with at least one disability and receiving personal help with one of them. The following Rasch model properties were studied in 14 items enquiring about basic and instrumental ADL: fit to the model, reliability, unidimensionality, local independency between items and differential item functioning (DIF) by gender, age and proxy. The unidimensionality of the scale was confirmed. The final analysis of eight items showed a satisfactory fit, good reliability, local independency, unidimensionality and no DIF by age. The disability linear measure showed significant differences by gender and age. The obtained disability scale is a simple and reliable measure, and it suggests a hierarchical order of ADL and predicts a schedule of functional impairment in older adults. Rating the disability of older community-dwelling people has a predictive value that policy makers might find useful in service planning.

The Adults and Older Adults Functional Assessment Inventory

Functional assessment methods are an important element in multidimensional neuropsychological evaluations, particularly in older adults. The Adults and Older Adults Functional Assessment Inventory is a new measure of basic and instrumental activities of daily living. Rasch model analyses were used to analyze the psychometric characteristics of the instrument in a sample of 803 participants. The original categories did not provide an optimal assessment of functional incapacity. The scale was dichotomized to achieve a better reliability score and item fit. The final 50 items revealed a moderately high variability in item difficulty, acceptable fits to items and persons, and a good Person Separation Reliability score. The scores were able to discriminate between normal controls and clinical patients. None of the items showed Differential Item Functioning associated with age, gender, or education. The instrument is able to achieve measures of functional incapacity with the useful properties of the Rasch model.

Development of an Expanded Measure of Physical Functioning for Older Persons in Epidemiologic Research

We scaled a measure of physical functioning to a population-based normative sample by extending self-reported basic and instrumental activities of daily living with items from the Medical Outcomes Study 12-Item Short Form Survey. We used item response theory to place items administered to a sample of older elective surgery patients on a common metric linked to the Patient Reported Outcomes Measurement Information System (PROMIS) normative sample using published data. The summary measure for physical functioning was internally consistent (Cronbach's α = .83), reliable across a broad range of functioning, and was moderately correlated with walking speed (r = .52) and energy expenditure (r = .40). Demonstrating predictive criterion validity, less impaired scores were associated with lower risk of discharge to a rehabilitation facility (odds ratio = .38, 95% confidence interval [CI] [0.22, 0.66]) and shorter hospital stays (incidence rate ratio [IRR] = 0.87, 95% CI [0.79, 0.97]). Our approach may facilitate direct comparison of physical functioning measures across existing and future studies using a common, population-based metric, when overlapping items with the National Institutes of Health (NIH) PROMIS item bank are present.

Lawton IADL scale in dementia: can item response theory make it more informative?

BACKGROUND

impairment of functional abilities represents a crucial component of dementia diagnosis. Current functional measures rely on the traditional aggregate method of summing raw scores. While this summary score provides a quick representation of a person's ability, it disregards useful information on the item level.

OBJECTIVE

to use item response theory (IRT) methods to increase the interpretive power of the Lawton Instrumental Activities of Daily Living (IADL) scale by establishing a hierarchy of item 'difficulty' and 'discrimination'.

METHODS

this cross-sectional study applied IRT methods to the analysis of IADL outcomes. Participants were 202 members of the Scottish Dementia Research Interest Register (mean age = 76.39, range = 56-93, SD = 7.89 years) with complete itemised data available.

RESULTS

a Mokken scale with good reliability (Molenaar Sijtsama statistic 0.79) was obtained, satisfying the IRT assumption that the items comprise a single unidimensional scale. The eight items in the scale could be placed on a hierarchy of 'difficulty' (H coefficient = 0.55), with 'Shopping' being the most 'difficult' item and 'Telephone use' being the least 'difficult' item. 'Shopping' was the most discriminatory item differentiating well between patients of different levels of ability.

CONCLUSIONS

IRT methods are capable of providing more information about functional impairment than a summed score. 'Shopping' and 'Telephone use' were identified as items that reveal key information about a patient's level of ability, and could be useful screening questions for clinicians.

Effect of occupation- and activity-based interventions on instrumental activities of daily living performance among community-dwelling older adults: a systematic review

This systematic review examines the effectiveness of occupation- and activity-based interventions on community-dwelling older adults' performance of instrumental activities of daily living (IADLs). It was conducted as part of the American Occupational Therapy Association's Evidence-Based Practice Project. Forty studies met the inclusion criteria and were critically appraised and synthesized. Within occupation-based and client-centered interventions, the evidence that multicomponent interventions improve and maintain IADL performance in community-dwelling older adults is strong. The results also indicate that client-centered, occupation-based interventions can be effective in improving and maintaining IADL performance. The evidence is moderate for functional task exercise programs and limited for simulated IADL interventions to improve IADL performance. In the area of performance skills, the evidence related to physical activity and cognitive skills training is mixed, and the evidence that vision rehabilitation interventions improve IADL performance in older adults with low vision is moderate. Implications for practice, education, and research are also discussed.

Multiple chronic conditions and limitations in activities of daily living in a community-based sample of older adults in New York City, 2009

Introduction

Nationally, 60% to 75% of older adults have multiple (2 or more) chronic conditions (MCCs), and the burden is even higher among low-income, racial/ethnic minority populations. MCCs limit activities of daily living (ADLs), yet this association is not well characterized outside of clinical populations. We examined the association of MCCs with ADLs in a racially/ethnically diverse population of low-income older adults living in New York City public housing.

Methods

A representative sample of 1,036 New York City Housing Authority residents aged 65 or older completed a telephone survey in June 2009. We examined the association of up to 5 chronic conditions with basic ADL (BADL) limitations, adjusting for potential confounders by using logistic regression.

Results

Of respondents, 28.7% had at least 1 BADL limitation; 92.9% had at least 1 chronic condition, and 79.0% had MCCs. We observed a graded association between at least 1 BADL limitation and number of chronic conditions (using 0 or 1 condition as the reference group): adjusted odds ratio (AOR) for 3 conditions was 2.2 (95% confidence interval [CI], 1.3–3.9); AOR for 4 conditions, 4.3 (95% CI, 2.5–7.6); and AOR for 5 conditions, 9.2 (95% CI, 4.3–19.5).

Conclusion

Prevalence of BADL limitations is high among low-income older adults and increases with number of chronic conditions. Initiating prevention of additional conditions and treating disease constellations earlier to decrease BADL limitations may improve aging outcomes in this population.