Tracking progress toward national health objectives in the elderly: what do restricted activity days signify?

The role of intervening illnesses and injuries in prolonging the disabling process

OBJECTIVES

To evaluate the relationship between intervening illnesses and injuries leading to hospitalization and restricted activity, respectively, and prolongation of disability in four essential activities of daily living in newly disabled older persons.

DESIGN

Prospective cohort study.

SETTING

Greater New Haven, Connecticut.

PARTICIPANTS

Community-living persons aged 70 and older who had at least one episode of disability from March 1998 to June 2013 (N=632).

MEASUREMENTS

Disability and exposure to intervening illesses and injuries leading to hospitalization and restricted activity, respectively, were assessed every month. Prolongation of disability was operationalized in two complementary ways: as a dichotomous outcome, based on the persistence of any disability, and as a count of the number of disabled activities.

RESULTS

During a median follow-up of 114 months, the 632 participants experienced 2,764 disability episodes. The mean exposure rates for hospitalization and restricted activity were 80.7 (95% confidence interval (CI)=73.7-88.4) and 173.6 (95% CI=162.5-185.5), respectively, per 1,000 person-months. After adjustment for multiple disability risk factors, the likelihood of disability prolongation was 2.5 times as great (odds ratio (OR) 2.54, 95% CI=2.05-3.15) for hospitalization and 1.2 times as great (1.21, 95% CI=1.06-1.40) for restricted activity as for no hospitalization or restricted activity, and the mean number of disabilities was 35% (risk ratio (RR)=1.35, 95% CI=1.30-1.39) greater in the setting of hospitalization and 7% (1.07, 95% CI=1.05-1.09) greater in the setting of restricted activity.

CONCLUSION

Intervening illnesses and injuries leading to hospitalization and restricted activity, respectively, are strongly associated with prolongation of disability in newly disabled older adults. Efforts to prevent and more-aggressively manage these intervening events have the potential to break the cycle of disability in older persons.

Functional outcomes of multi-condition collaborative care and successful ageing: results of randomised trial

OBJECTIVE

To evaluate the effectiveness of integrated care for chronic physical diseases and depression in reducing disability and improving quality of life.

DESIGN

A randomised controlled trial of multi-condition collaborative care for depression and poorly controlled diabetes and/or risk factors for coronary heart disease compared with usual care among middle aged and elderly people

SETTING

Fourteen primary care clinics in Seattle, Washington.

PARTICIPANTS

Patients with diabetes or coronary heart disease, or both, and blood pressure above 140/90 mm Hg, low density lipoprotein concentration >3.37 mmol/L, or glycated haemoglobin 8.5% or higher, and PHQ-9 depression scores of ≥ 10.

INTERVENTION

A 12 month intervention to improve depression, glycaemic control, blood pressure, and lipid control by integrating a "treat to target" programme for diabetes and risk factors for coronary heart disease with collaborative care for depression. The intervention combined self management support, monitoring of disease control, and pharmacotherapy to control depression, hyperglycaemia, hypertension, and hyperlipidaemia.

MAIN OUTCOME MEASURES

Social role disability (Sheehan disability scale), global quality of life rating, and World Health Organization disability assessment schedule (WHODAS-2) scales to measure disabilities in activities of daily living (mobility, self care, household maintenance).

RESULTS

Of 214 patients enrolled (106 intervention and 108 usual care), disability and quality of life measures were obtained for 97 intervention patients at six months (92%) and 92 at 12 months (87%), and for 96 usual care patients at six months (89%) and 92 at 12 months (85%). Improvements from baseline on the Sheehan disability scale (-0.9, 95% confidence interval -1.5 to -0.2; P = 0.006) and global quality of life rating (0.7, 0.2 to 1.2; P = 0.005) were significantly greater at six and 12 months in patients in the intervention group. There was a trend toward greater improvement in disabilities in activities of daily living (-1.5, -3.3 to 0.4; P = 0.10).

CONCLUSIONS

Integrated care that covers chronic physical disease and comorbid depression can reduce social role disability and enhance global quality of life. Trial registration Clinical Trials NCT00468676.

A five state dissemination of a community-based disability prevention program for older adults

OBJECTIVE

To describe challenges in disseminating the Health Enhancement Program (HEP), a community-based disability prevention program for community dwelling elders, and to examine program effectiveness in geographically dispersed sites.

METHODS

Within-group, pre-test-post-test comparisons of disability risk factors, health and functional status, and hospitalizations for 115 participants completing one year in HEP, and primary care provider awareness and perceptions of the program.

RESULTS

Most (77%) participants were women, with an average age of 73 years and an average of 3.5 chronic conditions. At one-year follow-up, compared with enrollment, fewer participants were depressed (8.8% vs 15.9%), physically inactive (15.8% vs 38.6%), at high nutritional risk (24.3% vs 44.1%), or experiencing restricted activity days (35% vs 48%). Severity scores on most measures also improved significantly. The proportion hospitalized was unchanged from the year prior to HEP, although risk factors predicted an increase in hospitalizations as for the control group in the randomized trial.

CONCLUSIONS

HEP reduced participants' disability risk factors. Sites varied on numbers enrolled and time to implement the program, likely due to differing referral bases, degree of physician awareness of HEP, and site readiness. However, the benefits of HEP participation were comparable with those reported previously.

The relationship between psychological factors and disabling musculoskeletal pain in community-dwelling older persons

OBJECTIVES

To determine the relationship between two psychological factors (depressive symptoms and low functional self-efficacy) and the occurrence of disabling musculoskeletal pain in community-dwelling older persons.

DESIGN

A 12-month prospective cohort study.

SETTING

Community-based.

PARTICIPANTS

Two hundred twenty-six community-dwelling persons residing in the greater New Haven, Connecticut, region, aged 70 and older, who had a history of clinically evident musculoskeletal pain and were independent in bathing, walking, dressing, and transferring.

MEASUREMENTS

Levels of depressive symptoms and functional self-efficacy were determined during a comprehensive baseline assessment along with information regarding participants' demographic, medical, and physical/cognitive status. The occurrence of disabling musculoskeletal pain, defined as staying in bed for at least one-half day or cutting down on one's usual activities due to joint or back pain, was ascertained during monthly interviews.

RESULTS

The mean number of months of disabling musculoskeletal pain, adjusted for baseline covariates, increased from the lowest to the highest quartile of depressive symptoms: 1.2 (95% confidence intervals = 0.8-1.7), 1.4 (1.0-2.0), 2.0 (1.5-2.8), 2.3 (1.7-3.1), respectively, P for trend =.002. The corresponding results for functional self-efficacy were (from highest to lowest quartile) 1.4 (1.0-2.0), 1.6 (1.2-2.2), 1.6 (1.2-2.2), 2.2 (1.6-3.0), P for trend =.068. There was no interaction between depressive symptoms and functional self-efficacy.

CONCLUSION

Depressive symptoms and, to a lesser extent, low functional self-efficacy were each associated with the occurrence of disabling musculoskeletal pain among community-dwelling older persons.

Outcomes of a community-based dissemination of the health enhancement program

OBJECTIVES

We previously found in an efficacy trial that a health promotion program prevented functional decline and reduced hospitalizations in community-dwelling older people with chronic conditions. We sought to evaluate the effectiveness of the program in its dissemination phase.

DESIGN

Outcome evaluation using a within-group, pretest-posttest design.

SETTING

Fourteen senior centers located throughout western Washington.

PARTICIPANTS

Three hundred four community-dwelling men and women aged 65 and older.

INTERVENTION

A disability-prevention, chronic disease-self-management program.

MEASUREMENTS

Participant characteristics, risk factors for disability, change in health and functional status, and healthcare use over 1 year of enrollment; participant satisfaction.

RESULTS

Participants were 71% female, had a mean age of 76, and reported three chronic health conditions on average. The percentage of participants found to be depressed decreased (28% at time of enrollment vs 17% at 1-year follow-up, P =.005). The percentage of physically inactive participants decreased (56% vs 38%, P =.001). Physical activity level and exercise readiness improved (Physician-based Assessment and Counseling for Exercise mean score 4.3 vs 5.1, P =.001). At follow-up, 83% rated their health the same as or better than a year ago, compared with 73% at time of enrollment. The proportion with impaired functional status, as measured by bed days and restricted activity days, stayed the same. The proportion hospitalized remained stable (23% at enrollment and follow-up, P = 1.0).

CONCLUSIONS

Under real world conditions, the Health Enhancement Program reaches older people at risk of functional decline. Those enrolled for 1 year experience a reduction in disability risk factors, improvement in health status, no decrements in functional status, and no increase in self-reported healthcare use.

Is the use of benzodiazepines associated with incident disability?

OBJECTIVES

This study examined the association between benzodiazepine use and incident disability with an emphasis on elucidating whether the underlying health conditions that result in benzodiazepine use (confounding factors) or intrinsic adverse effects of benzodiazepine use were responsible for functional decline.

DESIGN

Cohort study with follow-up of 4 to 5 years.

SETTING

A health maintenance organization (HMO) in western Washington.

PARTICIPANTS

Individuals aged 65 and older from a random sample of HMO enrollees who participated in a health promotion intervention trial (n = 1,519).

MEASUREMENTS

Benzodiazepine use was ascertained from computerized pharmacy records. Self-reported functional status was assessed using a six-item physical function scale ranging from vigorous activity to self-care activities of daily living (ADLs). Two outcomes were examined: decline in overall physical function and limitations in self-care ADLs. Multivariate models were examined that included demographic characteristics, health status, and health behaviors that were likely to be confounders. Several analyses were conducted to examine whether benzodiazepine use or confounding factors were responsible for functional decline.

RESULTS

Benzodiazepine use was significantly associated with incident loss of physical function (hazard ratio (HR) = 1.51, 95% confidence interval (CI) = 1.02-2.24) in the fully adjusted model. Although use of benzodiazepines was associated with limitations in ADLs, it was not significant when adjusting for other factors (HR = 1.71, 95% CI = 0.87-3.34). Several of our findings suggest that the health conditions leading to benzodiazepine use may partly or fully explain these associations: (1) use of anxiolytic benzodiazepines (HR = 1.95, 95% CI = 1.24-3.07), but not hypnotic agents (HR = 1.21, 95% CI = 0.73-2.00), was associated with functional decline; (2) adjustment for health status variables minimized these associations; and (3) there was little evidence of dose response.

CONCLUSIONS

A modestly increased risk for decline in physical function was associated with benzodiazepine use, especially of anxiolytic agents. The health conditions that result in benzodiazepine use may be more important in the pathogenesis of disability than benzodiazepine use itself. Although there are many reasons for avoiding benzodiazepines in older adults, it is still unclear whether use contributes independently to functional decline.

Disability and its economic impact among adults with diabetes

The objective of this study was to estimate the annual cost of disability among people with diabetes. Data from the 1994 Behavioral Risk Factor Surveillance System (n = 83,566) of US individuals aged 18 to 64 years were used to estimate the annual cost of disability among people with self-reported diabetes. After we adjusted for relevant socioeconomic characteristics, logistic regression analyses demonstrated that people with diabetes are more likely to stop working outside the home (for men: adjusted odds ratio, 3.1; 95% confidence interval, 1.2 to 8.0; for women: adjusted odds ratio, 2.9; 95% confidence interval, 1.0 to 8.8). The annual cost of disability among people with diabetes was estimated at $9.3 billion in 1994. Disability among people with diabetes is a major public health problem. Efforts to reduce disability in this population could create substantial gains in productivity.

A Randomized Clinical Trial of Outpatient Geriatric Evaluation and Management

OBJECTIVES

To measure the effects of outpatient geriatric evaluation and management (GEM) on high-risk older persons' functional ability and use of health services.

DESIGN

Randomized clinical trial.

SETTING

Ambulatory clinic in a community hospital.

PARTICIPANTS

A population-based sample of community-dwelling Medicare beneficiaries age 70 and older who were at high risk for hospital admission in the future (N = 568).

INTERVENTION

Comprehensive assessment followed by interdisciplinary primary care.

MEASUREMENTS

Functional ability, restricted activity days, bed disability days, depressive symptoms, mortality, Medicare payments, and use of health services. Interviewers were blinded to participants' group status.

RESULTS

Intention-to-treat analysis showed that the experimental participants were significantly less likely than the controls to lose functional ability (adjusted odds ratio (aOR) = 0.67, 95% confidence interval (CI) = 0.47-0.99), to experience increased health-related restrictions in their daily activities (aOR = 0.60, 95% CI = 0.37-0.96), to have possible depression (aOR = 0.44, 95% CI = 0.20-0.94), or to use home healthcare services (aOR = 0.60, 95% CI = 0.37-0.92) during the 12 to 18 months after randomization. Mortality, use of most health services, and total Medicare payments did not differ significantly between the two groups. The intervention cost $1,350 per person.

CONCLUSION

Targeted outpatient GEM slows functional decline.

The use of proxy respondents in studies of older adults: lessons, challenges, and opportunities

OBJECTIVE

Proxies play a critical role as sources of health information for older persons with cognitive impairment and other chronic debilitating conditions. This paper reviews the validity of proxy responses for people older than age 60 in the following areas: functioning, physical and mental health, cognition, medical care utilization, and preferences for types of care and health states.

DESIGN

A Medline review identified 24 clinical studies from 1990 to 1999 that use proxy data as a source of information about older adults.

RESULTS

In general, studies report fairly good agreement between subjects and proxies in assessments of functioning, physical health, and cognitive status, and fair-to-poor agreement in assessments of psychological well-being. Proxies tend to describe more impairment in functioning and emotional well-being, relative to subjects, a pattern that is particularly marked among persons with cognitive impairment. In addition, proxies who report more caregiver responsibilities and subjective stress from caregiver duties provide more negative assessments of subjects' health and well-being.

CONCLUSIONS

Findings tend to support the use of proxy ratings among older adults in many areas but not all when self-reports are not feasible. There is a need for more evaluation of proxy data in relation to other measures, such as performance assessments, medical records, and claims data, which may be less subject to respondent biases.

A randomized clinical trial of outpatient comprehensive geriatric assessment coupled with an intervention to increase adherence to recommendations

BACKGROUND

Although comprehensive geriatric assessment (CGA) has been demonstrated to confer health benefits in some settings, its value in outpatient or office settings is uncertain.

OBJECTIVE

To assess the effectiveness of outpatient CGA consultation coupled with an adherence intervention on 15-month health outcomes.

DESIGN

A randomized controlled trial.

SETTING

Community-based sites.

PATIENTS

363 community-dwelling older persons who had failed a screen for at least one of four conditions (falls, urinary incontinence, depressive symptoms, or functional impairment)

INTERVENTION

A single outpatient CGA consultation coupled with an intervention to improve primary care physician and patient adherence with CGA recommendations.

MEASUREMENTS

Medical Outcomes Study Short Form-36 (MOS SF-36), restricted activity and bed days, Physical Performance Test, NIA lower-extremity battery.

RESULTS

In complete case analysis (excluding the five control group subjects who died during the follow-up period), the adjusted difference in change scores (4.69 points) for physical functioning between treatment and control groups indicated a significant benefit of treatment (P = .021). Similar benefits were demonstrated for number of restricted activity days and MOS SF-36 energy/fatigue, social functioning, and physical health summary scales. In analyses assigning scores of 0 to those who died, these benefits were greater, and significant benefits for the Physical Performance Test and MOS SF-36 emotional/well being, pain, and mental health summary scales were also demonstrated.

CONCLUSIONS

A single outpatient comprehensive geriatric assessment coupled with an adherence intervention can prevent functional and health-related quality-of-life decline among community-dwelling older persons who have specific geriatric conditions.

Preventing disability and managing chronic illness in frail older adults: a randomized trial of a community-based partnership with primary care

BACKGROUND

Effective new strategies that complement primary care are needed to reduce disability risks and improve self-management of chronic illness in frail older people living in the community.

OBJECTIVE

To evaluate the impact of a 1-year, senior center-based chronic illness self-management and disability prevention program on health, functioning, and healthcare utilization in frail older adults.

DESIGN

A randomized controlled trial.

SETTING

A large senior center located in a northeast Seattle suburb. The trial was conducted in collaboration with primary care providers of two large managed care organizations.

PARTICIPANTS

A total of 201 chronically ill older adults seniors aged 70 and older recruited through medical practices.

INTERVENTION

A targeted, multi-component disability prevention and disease self-management program led by a geriatric nurse practitioner (GNP).

MEASUREMENTS

Self-reported Physical function, physical performance tests, health care utilization, and health behaviors.

RESULTS

Each of 101 intervention participants met with the GNP from 1 to 8 times (median = 3) during the study year. The intervention group showed less decline in function, as measured by disability days and lower scores on the Health Assessment Questionnaire. Other measures of function, including the SF-36 and a battery of physical performance tests, did not change with the intervention. The number of hospitalized participants increased by 69% among the controls and decreased by 38% in the intervention group (P = .083). The total number of inpatient hospital days during the study year was significantly less in the intervention group compared with controls (total days = 33 vs 116, P = .049). The intervention led to significantly higher levels of physical activity and senior center participation and significant reductions in the use of psychoactive medications.

CONCLUSIONS

This project provides evidence that a community-based collaboration with primary care providers can improve function and reduce inpatient utilization in chronically ill older adults. Linking organized medical care with complementary community-based interventions may be a promising direction for research and practice.

Racial differences in functional status among elderly U.S. migrants from the South

This study describes patterns of functional status among older blacks and whites by their history of birth in and migration out of the South. We used multivariate regression to analyze data on functional status of US-born non-Hispanic blacks (N = 1868) and whites (N = 13469) age 60 years or above. In general, the functional status of blacks who were born in the South and migrated was similar to that of blacks born outside the South and better than those born in the South who did not migrate. Whites who migrated from the South had functional status similar to those who did not migrate and worse than those born outside of the South. Socioeconomic status did not explain differences by race and migration history. These results differ sharply from mortality studies, which have found a consistent pattern of high mortality among black migrants from the South. Differences among race groups by migration history vary across health measures. Selective migration and selective survival may account for the complex patterns of racial differences in geographic distributions of function and health.

Performance of a self-administered mailed version of the Quality of Well-Being (QWB-SA) questionnaire among older adults

OBJECTIVES

The Quality of Well-Being questionnaire is a measure of health-related quality of life (HRQoL) that has several desirable properties. Its widespread use has been hindered because it is difficult to administer. To overcome this limitation, a new self-administered form has recently been developed. This study examined the feasibility of using the Quality of Well-Being-Self-Administered (QWB-SA) questionnaire in an older population.

METHODS

The Quality of Well-Being-Self-Administered questionnaire was sent to 430 community-dwelling individuals aged 65 years and older who were randomly selected from primary care physicians' offices. Response patterns, scaling distributions, and the acceptability of the survey were examined for all respondents. The results of the QWB-SA questionnaire were compared to the Sickness Impact Profile (SIP) and the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) for those individuals who also had completed the latter two surveys approximately 10 months earlier and whose health had not changed substantially in the meantime.

RESULTS

Three hundred and one older adults (70%) responded. The mean QWB-SA questionnaire score was 0.7035. The scores were not skewed, and there were no floor or ceiling effects. The mean time to complete the QWB-SA questionnaire was 14.2 minutes, which was significantly shorter than for the SIP (19.3 minutes) but significantly longer than for the SF-36 (12.5 minutes). Subjects rated their satisfaction with the QWB-SA questionnaire somewhat lower than for the SIP and similar to SF-36. Correlations between the QWB-SA questionnaire and the SIP and SF-36 were moderate and were generally stronger for measures of physical health than for other domains such as mental health.

CONCLUSIONS

The self-administered QWB questionnaire was acceptable to older respondents, and it correlated with other measures of health-related quality of life. It can be considered as a candidate for some research applications among older adults.

Selecting a generic measure of health-related quality of life for use among older adults. A comparison of candidate instruments

Selecting an outcomes assessment instrument requires knowledge of their relative merits, especially head-to-head comparisons. The authors compare health-related quality-of-life (HRQOL) instruments among older adults for their psychometric properties and subject burden, specifically the Sickness Impact Profile (SIP) and Medical Outcomes Study Short-Form 36 (SF-36). Subjects were 282 of 373 eligible older adults (75.6% response) ranging in age from 65 to 96. SIP scores demonstrated a strong skew toward low (good health) scores with a mean of 11.1% (+/- SD 11.5) on the Total SIP index score. Similar components of the SIP and SF-36 were moderately to strongly correlated. The SIP suffered from a ceiling (good health) scaling effect, and the SF-36 scales also demonstrated some scaling extremes. These results demonstrate the relative scaling limits, especially the ceiling effect, of the SIP compared to the SF-36, and in general, the SF-36 is preferred for use among community-living older adults.

The health burdens of Parkinson's disease

Parkinson's disease (PD) is likely to have a substantial impact on an individual's health-related quality of life (HRQL), health-related resource use, and productivity. Data about the health burdens of PD by disease stage are fundamental to understanding the effectiveness of care, both from a clinical and a fiscal point of view. This study's goal was to describe the associations of patient-reported HRQL and economic characteristics with PD stage. We hypothesized that later stages of PD would be associated with poorer HRQL, greater health-related resource use, and lower work productivity than early stages of PD. We used a cross-sectional analysis to study 193 PD patients attending two hospital-based neurology clinics. Self-administered questionnaires and in-person interviews measured clinical features, functional status, general health perceptions, well-being, overall HRQL, work productivity, and health-related resource use. Consistent, strong associations were found between stage and functional status, general health perceptions, well-being, and overall HRQL even after controlling for age, gender, and comorbid conditions. Most resource use and work productivity measures were also associated with disease stage. However, physician services use was not. This study confirms that the burdens of illness are progressively higher for PD patients with early, moderate, and advanced illness. The results suggest that such important facets of the health burden as HRQL and health-related resource use may be seriously misjudged if not carefully measured but inferred from clinical observations alone.

Predicting hospitalization and functional decline in older health plan enrollees: are administrative data as accurate as self-report?

OBJECTIVE

To compare the predictive accuracy of two validated indices, one that uses self-reported variables and a second that uses variables derived from administrative data sources, to predict future hospitalization. To compare the predictive accuracy of these same two indices for predicting future functional decline.

DESIGN

A longitudinal cohort study with 4 years of follow-up.

SETTING

A large staff model HMO in western Washington State.

PARTICIPANTS

HMO Enrollees 65 years and older (n = 2174) selected at random to participate in a health promotion trial and who completed a baseline questionnaire.

MEASUREMENT

Predicted probabilities from the two indices were determined for study participants for each of two outcomes: hospitalization two or more times in 4 years and functional decline in 4 years, measured by Restricted Activity Days. The two indices included similar demographic characteristics, diagnoses, and utilization predictors. The probabilities from each index were entered into a Receiver Operating Characteristic (ROC) curve program to obtain the Area Under the Curve (AUC) for comparison of predictive accuracy.

RESULTS

For hospitalization, the AUC of the self-report and administrative indices were .696 and .694, respectively (difference between curves, P = .828). For functional decline, the AUC of the two indices were .714 and .691, respectively (difference between curves, P = .144).

CONCLUSIONS

Compared with a self-report index, the administrative index affords wider population coverage, freedom from nonresponse bias, lower cost, and similar predictive accuracy. A screening strategy utilizing administrative data sources may thus prove more valuable for identifying high risk older health plan enrollees for population-based interventions designed to improve their health status.

Psychopathology and the development of disability

The objective was to determine the effect of preexisting psychopathology on days missed from work or usual activities ("disability days") in a large community sample (N = 3481). Logistic regression analyses were performed with the presence or absence of disability days (wave 2) as the dependent variable. The effects of sociodemographic variables, six psychiatric disorders, a high distress score, and chronic physical conditions (wave 1) were studied. Separate analyses were conducted for the total sample and four subgroups (labor force participants, homemakers, men, and women). The adjusted odds ratios and 95% confidence intervals (95% CI) for subjects with onset of panic disorder were 7.3 (95% CI = 1.8, 28.7); for those with chronic major depressive disorder, 7.2 (95% CI = 0.3, 160.6); and for those with chronic high distress, 5.0 (95% CI = 2.6, 9.9). The relative odds for developing a disability were greater for those with either type of psychiatric disorder or high distress than for those with any prior physical illness or those with a prior disability day. Disability days experienced by persons with psychopathology result in diminished quality of life, economic losses, and increased need for health services. Improved health services and educational and work adjustments for emotionally disabled persons are recommended.

Controlled trial of a geriatric case-finding and liaison service in an emergency department

OBJECTIVE

To evaluate the effects of a program of case-finding and liaison service for older patients visiting the emergency department.

DESIGN

Nonrandomized controlled trial with systematically assembled intervention cohort and matched control group.

SETTING

An urban teaching hospital.

PARTICIPANTS

There were 385 intervention subjects aged 65 years and older and 385 control subjects matched by day of visit, gender, and age within 5 years.

INTERVENTIONS

Geriatric medical, dental and social problems were identified in intervention subjects by a geriatric nurse clinician using well validated assessment instruments during a 30-minute evaluation. Recommendations were made to the patient, family, and attending emergency department physician, and attempts were made to arrange appropriate follow-up services.

MEASUREMENTS

Frequency with which geriatric problems were identified in intervention subjects; physician, patient, and family compliance with recommendations; and mortality, institutionalization, health status, use of medical and social services, presence of an advanced directive, and quality of life at 3-month follow-up.

RESULTS

Sixty-seven percent of patients were dependent in at least one activity of daily living, 82% had at least one geriatric problem identified, and 77% reported at least one unmet dental or social support need. The cost of identifying geriatric and dental/social issues was $5 and $1, respectively, for each problem. Physicians compiled with 61.6% of suggestions, and patients and families complied with 36.6% of recommendations. Mortality and nursing home residence proportions at 3 months were not significantly different (9.3% vs 9.7% and 5.0% vs 2.5% in intervention and control groups, respectively). Intervention subjects reported more difficulty communicating (21% fair or poor ability vs 13%, P = 0.2) than did control subjects. There were strong trends for fewer subsequent visits to emergency departments (0.26 intervention vs 0.39 control, P = .06) and more advance directives in the intervention group (6.7% intervention vs 2.9% control, P = .07). There was no statistically or clinically significant difference in any other health outcome. The number of new dental or social services initiated per patient over the 3-month follow-up was nearly identical (1.7 in the intervention group vs 1.5 in the control). Results in subjects aged 75 years and older and those discharged home from the emergency department were essentially identical to those in the main group.

CONCLUSIONS

Numerous previously unrecognized geriatric medical and social problems can be detected in older persons visiting the emergency department. Despite this, an emergency department-based geriatric assessment and management program failed to produce improved outcomes. This suggests that either disease acuity is an overwhelming factor in subsequent outcome or, alternatively, more control over medical and social service delivery during and after the emergency department visit than was demonstrated in this program will be required before successful outcomes can be assured.

Self-report disability in an international primary care study of psychological illness

We assessed the replicability of reliability and validity of a brief self-report disability scale, adapted from the Medical Outcomes Survey (short form), in a 15-center, cross-national, multilingual study of psychological illness among primary care patients (n = 5438). Across all 15 centers in the World Health Organization Collaborative Study of Psychological Problems in General Health Care, the reliability of the disability scale was high and individual items were responsive at similar levels of disability. Self-report disability was consistently correlated with disability in work role (including housework) as rated by interviewers according to the Groningen Social Disability Schedule, a semistructured method taking local norms into account. Disability as measured by the self-report questionnaire was also consistently correlated with depressive symptoms as measured by the General Health Questionnaire. At each center, the disability items formed a moderately to strongly hierarchical (Guttman-like) scale. These findings support the feasibility of using self-report disability scales in cross-national primary care research.

Does walking decrease the risk of cardiovascular disease hospitalizations and death in older adults?

OBJECTIVES

The purpose of this study was to determine whether walking is associated with a reduced risk of cardiovascular disease hospitalization and death in community-dwelling older men and women.

DESIGN

A prospective study, with follow-up time of 4 to 5 years (average 4.2 years).

SETTING

A western Washington health maintenance organization.

PARTICIPANTS

Men and women aged 65 years and older from a random sample of HMO enrollees invited by mail to participate in a health promotion intervention trial (36% accepted the invitation and completed questionnaires). This report is based on 1645 older adults without severe disability and without history of heart disease. Vital status ascertainment was complete (100%), and only 2.6% did not complete the follow-up.

MEASUREMENTS

Reported frequency and duration of walking for exercise, work, errands, pleasure, and hiking in the 2 weeks before baseline were used to classify hours of walking per week. The two main outcomes were: (1) cardiovascular disease hospitalizations with a discharge diagnosis of coronary (ICD-9-CM 410-414) or other cardiovascular diseases (ICD-9-CM 390-409, 415-448) documented by computerized hospitalization records and (2) death. Numerous potential confounding factors were considered, including age, sex, treated high blood pressure, current estrogen use and chronic disease score (ascertained by computerized medical and pharmacy records), and ethnicity, education, income, physical function, self-rated health status, smoking, alcohol intake, and body mass index (ascertained by self-report on the mailed questionnaire).

RESULTS

Walking more than 4 hours/week was associated significantly with a reduced risk of cardiovascular disease hospitalization in both sexes combined compared with walking less than 1 hour/week (age and sex-adjusted relative risk = 0.69; 95% confidence interval, 0.52-0.90). This association was not altered by adjustment for baseline cardiovascular risk factors and indicators of general health status. The association was present in all age groups, among those with and without physical limitations, and also among those who did and did not also participate in more vigorous physical activities. Walking more than 4 hours/week was also associated with a reduced risk of death (age and sex-adjusted relative risk = 0.73; 95% confidence interval, 0.48-1.10), however, this association was substantially diminished by adjustment for cardiovascular risk factors and measures of general health status.

CONCLUSIONS

Walking more than 4 hours/week may reduce the risk of hospitalization for cardiovascular disease events. The association of walking more than 4 hours/week with reduced risk of death may be mediated by effects of walking on other risk factors. These findings provide much stronger evidence than previously available for advising older men and women to embark on or maintain a sustained program of walking to prevent cardiovascular disease events.

Functional health status of older women

By the year 2000 in the United States, there will be 32 million adults age 65 or over, representing 12% of the population, with the majority being women. Older women are experiencing greater longevity but worse overall health than men. The assessment of functional health status in older women is often neglected yet is the major contributor to independent living. Functional health status includes the dimensions of physical health, independent health, and psychosocial health. Studies of two different groups of non-institutionalized older women who reside in the same Southwestern state are discussed in relation to national study samples and implications for nurse practitioners.

Preventing disability and falls in older adults: a population-based randomized trial

OBJECTIVES

Because preventing disability and falls in older adults is a national priority, a randomized controlled trial was conducted to test a multicomponent intervention program.

METHODS

From a random sample of health maintenance organization (HMO) enrollees 65 years and older, 1559 ambulatory seniors were randomized to one of three groups: a nurse assessment visit and follow-up interventions targeting risk factors for disability and falls (group 1, n = 635); a general health promotion nurse visit (group 2, n = 317); and usual care (group 3, n = 607). Data collection consisted of a baseline and two annual follow-up surveys.

RESULTS

After 1 year, group 1 subjects reported a significantly lower incidence of declining functional status and a significantly lower incidence of falls than group 3 subjects. Group 2 subjects had intermediate levels of most outcomes. After 2 years of follow-up, the differences narrowed.

CONCLUSIONS

The results suggest that a modest, one-time prevention program appeared to confer short-term health benefits on ambulatory HMO enrollees, although benefits diminished by the second year of follow-up. The mechanisms by which the intervention may have improved outcomes require further investigation.

Emotional disability days: prevalence and predictors

This study considered days missed from work or usual activities for emotional reasons associated with a range of specific psychopathologic disorders, psychosocial distress, and persons found to be asymptomatic. Analyses were performed with the presence or absence of emotional disability days as the dependent variable using logistic regression. The effects of specific mental disorders were compared with the effects of chronic physical conditions for labor force participants and for the total population. The odds ratio (and 95% confidence interval) for subjects with major depressive disorder was 27.8 (6.93, 108.96); for panic disorder, 21.1 (2.25, 198.44); and for schizophrenia, 17.8 (1.73, 182.99). Work-place adjustments for persons with psychopathology are encouraged.

Responsiveness of health status measures to change among older adults

OBJECTIVE

This study examines the ability of commonly used self-reported health status measures to detect important changes in health (responsiveness) in older adults.

DESIGN

We compared changes in health status measures over the year among subgroups of a cohort of seniors: those who experienced an intervening illness, hospitalization or increase in drug regimen, and those who didn't. Differences between the two groups in changes in the measures were quantitated using Guyatt's responsiveness statistic and receiver operating characteristic curves (ROC).

SETTING

Staff model HMO.

PARTICIPANTS

1379 senior HMO enrollees who were participants in a health promotion trial and provided complete information at baseline and one year later.

MEASUREMENTS

The following self-reported health status measures were evaluated: restricted activity days, bed disability days, the Medical Outcomes Study physical function scale, self-evaluated health, and a positive affect scale.

MAIN RESULTS

All measures except the positive affect scale were able to discriminate significantly between seniors who were or were not hospitalized and/or reported a major illness in the intervening year. The two disability days measures showed the best responsiveness for all indicators of worsening health and included 70%-80% of the area under the ROC curves for major illness defined by hospitalization or self-report.

CONCLUSIONS

Commonly used, brief self-reported physical health status measures are responsive to intervening illness among relatively healthy seniors supporting their use in longitudinal geriatric research.

Restricted activity days among older adults

OBJECTIVES

The number of restricted activity days experienced by an individual in the course of a year is an important measure of functional well-being, particularly for older adults. We sought to determine multivariate associations between restricted activity days and various health conditions.

METHODS

We used data from the 1984 Supplement on Aging of the National Health Interview Survey to estimate the relationship between restricted activity days and age, gender, and the presence or absence of selected chronic conditions and falls for all noninstitutionalized people aged 65 years and over. Chronic conditions and falls accounted for most of the variance in the model.

RESULTS

Of an annual average of 31 restricted activity days, 6 days were associated with falls; 4 days with heart disease; 4 days with arthritis and rheumatism; 2 days each with high blood pressure, cerebrovascular disease, and visual impairment; and 1 day each with atherosclerosis, diabetes, major malignancies, and osteoporosis.

CONCLUSIONS

These results can be used in estimating the potential impact of health promotion programs on the health status of noninstitutionalized older adults.

A chronic disease score from automated pharmacy data

Using population-based automated pharmacy data, patterns of use of selected prescription medications during a 1 year time period identified by a consensus judgement process were used to construct a measure of chronic disease status (Chronic Disease Score). This score was evaluated in terms of its stability over time and its association with other health status measures. In a pilot test sample of high utilizers of ambulatory health care well known to their physicians (n = 219), Chronic Disease Score (CDS) was correlated with physician ratings of physical disease severity (r = 0.57). In a second random sample of patients (n = 722), its correlation with physician-rated disease severity was 0.46. In a total population analysis (n = 122,911), it was found to predict hospitalization and mortality in the following year after controlling for age, gender and health care visits. In a population sample (n = 790), CDS showed high year to year stability (r = 0.74). Based on health survey data, CDS showed a moderate association with self rated health status and self reported disability. Unlike self-rated health status and health care utilization, CDS was not associated with depression or anxiety. We conclude that scoring automated pharmacy data can provide a stable measure of chronic disease status that, after controlling for health care utilization, is associated with physician-rated disease severity, patient-rated health status, and predicts subsequent mortality and hospitalization rates. Specific methods of scoring automated pharmacy data to measure global chronic disease status may require adaptation to local prescribing practices. Scoring might be improved by empirical estimation of weighting factors to optimize prediction of mortality and other health status measures.