Disability, resources, role demands and mobility handicap

On Scaling Methodology and Environmental Influences in Disability Assessments: The Cumulative Structure of Personal and Instrumental ADL among Older Adults in a Swedish Rural District

The ADL Staircase is a hierarchical instrument for assessment of independence/dependence in personal and instrumental activities of daily living (P-ADL and I-ADL). Its development was based on Katz's ADL-Index, applying the same assessment principles. The cumulativity among the items has previously been confirmed in Swedish urban elderly population samples. The purpose of this study was to test the instrument in a rural setting. Due to local environmental conditions, the authors developed alternative definitions for the “transportation” item. Data collected using 133 respondents suggested a different cumulative order among the I-ADL items from that identified in urban samples, and significant gender differences were found. The scale's cumulativity was analysed in-depth, and it revealed different results depending on which scaling analyses were used. Environmental factors highlighted the methodological difficulties inherent in I-ADL assessments, and the results revealed a higher prevalence of disability compared to previous gerontological studies. In clinical practice, awareness of the consequences of I-ADL assessments' limited generalizability between settings is strongly recommended. The study also has theoretical implications for further understanding of the complexity of disablement.

Assessing Environmentally Determined Mobility Disability: Self-Report Versus Observed Community Mobility

OBJECTIVES

To examine the test-retest reliability and concurrent validity of a new self-report measure of mobility function by comparing it with observed mobility, self-reported activity of daily living (ADL) function, and performance-based measures of gait and balance.

DESIGN

Cross-sectional study involving two groups of older adults.

SETTING

Community sites in Seattle, Washington, and Waterloo, Ontario, Canada.

PARTICIPANTS

Fifty-four adults aged 70 and older, recruited.

MEASUREMENTS

Subjects completed the Environmental Analysis of Mobility Questionnaire (EAMQ), reporting frequency of encounter and avoidance of 24 features of the physical environment, grouped into eight dimensions, on two occasions 1 week apart. Subjects were observed and videotaped during six trips into the community; frequency of encounters with environmental features within the eight dimensions was recorded. EAMQ encounter and avoidance scores were compared with observed environmental encounters, with disability in ADLs and instrumental ADLs (IADLs), and lower extremity functional measures including the Short Physical Performance Battery (SPPB) and the Berg Balance Test.

RESULTS

EAMQ test-retest reliability was high for all eight dimensions (intraclass correlation coefficient range=0.81-1.0) and for summary encounter (0.98) and avoidance (0.96) scores. Observed mobility was significantly correlated (Spearman correlation = r) with EAMQ summary encounter (r=0.66) and avoidance (r=-0.58) scores. Moderate correlations were present between the EAMQ (encounter or avoidance) and observed mobility in the distance, temporal, terrain, posture, load, and density dimensions but not in the attention and ambient dimensions. EAMQ encounter/avoidance was significantly associated with ADL and IADL ability and performance on the SPPB and Berg Balance Test.

CONCLUSION

Self-reported frequency of encounter and avoidance of specific environmental features appears to be a valid method for determining environmentally specific mobility disability but needs to be confirmed in a larger sample.

Environmental components of mobility disability in community-living older persons

OBJECTIVES

To examine the relationship between characteristics of the physical environment and mobility disability in community-living older persons.

DESIGN

Cross-sectional study conducted on three groups of community-dwelling older adults.

SETTING

Community-dwelling older people in Seattle, Washington, and Waterloo, Ontario, Canada.

PARTICIPANTS

Fifty-four older adults (> or =70) were recruited from two geographic sites and grouped according to level of physical function (elite, physically able, physically disabled).

MEASUREMENT

Subjects reported on frequency of encounter versus avoidance of 24 features of the physical environment, grouped into eight dimensions, using a five-point ordinal scale (never, rarely, sometimes, often, always). Never and rarely responses were combined and coded as not encountered or not avoided, whereas the sometimes, often or always responses were combined and coded as encountered or avoided.

RESULTS

Disabled older adults reported fewer encounters with and concomitantly greater avoidance of physical challenges to mobility than nondisabled older adults. However, both encounter and avoidance varied by environmental dimension.

CONCLUSION

Results support the hypothesis that mobility disability results from an interaction of individual and environmental factors. Mobility disability is associated with avoidance of some, but not all, physically challenging features within the environment, suggesting that some environmental features may disable community mobility more than others.

Determination of loss of quality of life

Physiatrists are a valuable resource in legal settings, where assessment of functional capacity to perform work and of future medical needs must be determined. Physiatrists help determine what future medical care is needed to restore and maintain an individual at the maximum level of life function. This article focuses on the use of a quality of life (QOL) rehabilitation model, rather than a medical model, for enhancing functional performance, modifying environments, and facilitating patient coping. We discuss use of the QOL model to describe and influence a patient's physical, psychological, cognitive, vocational/economic, and social/leisure domains.

Older women's experience of living with chronic leg ulceration

In this study the authors sought to gain insight into the lives of older women, to focus on the experience of living with leg ulcers and to explore women's views by talking to them about their experiences. Twelve English-speaking women aged over 70 years who had experienced leg ulceration for 3 years or more were interviewed. Analysis of the interview text revealed two overarching themes: (i) gaining and maintaining control over vulnerable limb(s); and (ii) lifestyle consequences of chronic leg ulceration and impaired mobility. These themes contained several subthemes including: (i) nagging pain; (ii) self-expertise and infection; (iii) leakage, smell and embarrassment; (iv) fighting for skin and limb integrity; (v) wearing non-preferred apparel; (vi) loneliness; and (vii) coping, determination and hope. The findings of this research show that elderly women who live with leg ulcers experience multiple consequences. While the everyday problems of living with an unhealed would are addressed by the community nurse, other more subtle consequences may be overlooked. Recognition of the complex and sometimes hidden concerns of these women could help to avert the sense of helplessness which currently exists.

Spinal cord injury rehabilitation. 4. Individual experience, personal adaptation, and social perspectives

This learner-directed module highlights contemporary perspectives on personal success in the adjustment and adaptation of patients with spinal cord injury (SCI). It is the fourth in a series of five modules within the chapter on spinal cord injury rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This module explores models of the multisystem effects on a person after SCI, disablement, theories of adjustment, patient autonomy, quality of life, community experience, adaptations enhancing sexuality, and minimization of pain after SCI. Perspectives of the patient's experience in disablement, interdisciplinary person-centered rehabilitation, and success of the individual in chosen life roles are emphasized. The module is designed to update SCI issues reviewed in past syllabi.

Epidemiology of disabling neurological disease: how and why does disability occur?

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The impact of disabling arthritis

OBJECTIVE

To use the WHO International Classification of Impairments, Disabilities, and Handicaps (ICIDH) as a framework to conceptualize how arthritis affects people and how the effects might be minimized.

METHODS

The ICIDH framework emphasizes that the impact of arthritis in terms of handicap is a product of an interaction between a person's social and environmental setting and his or her level of impairment and disability. Data from the Canadian Health and Activity Limitation Survey are used to illustrate the impact for the handicap dimensions.

RESULTS

Among persons who have arthritis, 25% cannot leave their residence or can leave only with help (mobility dimension), 45% have at least some level of physical dependence (physical independence dimension), 18% never participate in social activities (social integration dimension), 51% of those under age 65 are not in the labor force and 76% never go out to events such as sports or movies (occupation dimension), and 42% have out-of-pocket expenses because of disability (economic self-sufficiency dimension).

CONCLUSION

Policies for the control of handicap require not only medical and rehabilitation interventions to reduce disability, but also consideration of environmental and other social factors.

Rehabilitation medicine

The nature of rehabilitation medicine is outlined in terms of its objectives, its methods, the patient groups which it seeks to help and its relationships to other specialties. Some major advances of recent years are discussed, such as the development of the impairment/disability/handicap framework. With particular emphasis upon neurological rehabilitation, the breadth of the specialty is then illustrated with examples of current preoccupations. These include recovery patterns of the damaged nervous system, testing the efficacy of existing therapies, applying new treatment techniques and developing quantitative measures of disability and handicap. Looking to the future, some key areas are identified where further advances might be sought.