Functional status measures for integrating medical and social care

Patient Satisfaction and Perceived Quality of Care Among Younger Medicare Beneficiaries According to Activity Limitation Stages

OBJECTIVE

To examine the association between activity limitation stages and patient satisfaction and perceived quality of medical care among younger Medicare beneficiaries.

DESIGN

Cross-sectional study.

SETTING

Medicare Current Beneficiary Survey (MCBS) for calendar years 2001-2011.

PARTICIPANTS

A population-based sample (N=9323) of Medicare beneficiaries <65 years of age living in the community.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

MCBS questions were categorized under 5 patient satisfaction and perceived quality dimensions: care coordination and quality, access barriers, technical skills of primary care physician (PCP), interpersonal skills of PCP, and quality of information provided by PCP. Persons were classified into an activity limitation stage (0-IV) which was derived from self-reported difficulty performing activities of daily living (ADL) and instrumental activities of daily living (IADL).

RESULTS

Compared to beneficiaries with no limitations at ADL stage 0, the adjusted odds ratios (95% confidence intervals) for stage I (mild) to stage IV (complete) for satisfaction with access barriers ranged from 0.62 (0.53-0.72) at stage I to a minimum of 0.31 (0.22-0.43) at stage IV. Similarly, compared to beneficiaries at IADL stage 0, satisfaction with access barriers ranged from 0.66 (0.55-0.79) at stage I to a minimum of 0.36 (0.26-0.51) at stage IV. Satisfaction with care coordination and quality and perceived quality of medical care were not associated with activity limitation stages.

CONCLUSIONS

Younger Medicare beneficiaries with disabilities reported decreased satisfaction with access to medical care, highlighting the need to improve access to health care and human services and to enhance workforce capacity to meet the needs of this patient population.

A Risk Scoring System for the Prediction of Functional Deterioration, Institutionalization, and Mortality Among Medicare Beneficiaries

OBJECTIVE

We sought to develop a risk scoring system for predicting functional deterioration, institutionalization, and mortality. Identifying predictors of poor health outcomes informs clinical decision-making, service provision, and policy development to address the needs of persons at greatest risk for poor health outcomes.

DESIGN

This is a cohort study with 21,257 community-dwelling Medicare beneficiaries 65 yrs and older who participated in the 2001-2008 Medicare Current Beneficiary Survey. Derivation of the model was conducted in 60% of the sample and validated in the remaining 40%. Multinomial logistic regression model generated β coefficients, which were used to create a risk scoring system. Our outcome was instrumental activity of daily living stage transitions (stable/improved function and functional deterioration), institutionalization, or mortality for 2 yrs of follow-up.

RESULTS

A total of 18 factors were identified for functional deterioration (P < 0.05). In the derivation cohort, the likelihood of functional deterioration ranged from 6.27% to 33.51%, risk of institutionalization from 0.07% to 12.13%, and risk of mortality from 2.13% to 31.83%, in comparison with stable/improved function.

CONCLUSIONS

A risk scoring system predicting Medicare beneficiaries' risk of functional deterioration, institutionalization, and mortality based on demographic and clinical indicators may feasibly be developed with implications for healthcare delivery.

Predicting 3-year mortality and admission to acute-care hospitals, skilled nursing facilities, and long-term care facilities in Medicare beneficiaries

PURPOSE

The ability to predict mortality and admission to acute care hospitals, skilled nursing facilities (SNFs), and long-term care (LTC) facilities in the elderly and how it varies by activity of daily living (ADL) and instrumental ADL (IADL) status could be useful in measuring the success or failure of economic, social, or health policies aimed at disability prevention and management. We sought to derive and assess the predictive performance of rules to predict 3-year mortality and admission to acute care hospitals, SNFs, and LTC facilities among Medicare beneficiaries with differing ADL and IADL functioning levels.

METHODS

Prospective cohort using Medicare Current Beneficiary Survey data from the 2001 to 2007 entry panels. In all, 23,407 community-dwelling Medicare beneficiaries were included. Multivariable logistic models created predicted probabilities for all-cause mortality and admission to acute care hospitals, SNFs, and LTC facilities, adjusting for sociodemographics, health conditions, impairments, behavior, and function.

RESULTS

Sixteen, 22, 14, and 14 predictors remained in the final parsimonious model predicting 3-year all-cause mortality, inpatient admission, SNF admission, and LTC facility admission, respectively. The C-statistic for predicting 3-year all-cause mortality, inpatient admission, SNF admission, and LTC facility admission was 0.779, 0.672, 0.753, and 0.826 in the ADL activity limitation stage development cohorts, respectively, and 0.788, 0.669, 0.748, and 0.799 in the ADL activity limitation stage validation cohorts, respectively.

CONCLUSIONS

Parsimonious models can identify elderly Medicare beneficiaries at risk of poor outcomes and can aid policymakers, clinicians, and family members in improving care for older adults and supporting successful aging in the community.

The Association Between Activity Limitation Stages and Admission to Facilities Providing Long-term Care Among Older Medicare Beneficiaries

OBJECTIVE

This study aimed to examine whether activity limitation stages are associated with admission to facilities providing long-term care (LTC).

DESIGN

Cohort study using Medicare Current Beneficiary Survey data from the 2005-2009 entry panels. A total of 14,580 community-dwelling Medicare beneficiaries 65 years or older were included. Proportional subhazard models examined associations between activity limitation stages and time to first LTC admission, adjusting for baseline sociodemographics and health conditions.

RESULTS

The weighted annual rate of LTC admission was 1.1%. In the adjusted model, compared to activity of daily living (ADL) stage 0, the hazard ratios (95% confidence intervals [CIs]) were 2.0 (1.5-2.7), 3.9 (2.9-5.4), 3.6 (2.5-5.3), and 4.7 (2.5-9.0) for ADL stage I (mild limitation), ADL stage II (moderate limitation), ADL stage III (severe limitation), and ADL stage IV (complete limitation), respectively. Compared to instrumental ADL (IADL) stage 0, the hazard ratios, and 95% CIs for IADL stages I to IV were 2.0 (1.4-2.7), 3.7 (2.6-5.4), 4.6 (3.3-6.5), and 7.6 (4.6-12.3), respectively.

CONCLUSIONS

Activity limitation stages are strongly associated with future admission to LTC and may therefore be useful in identifying specific supportive care needs among vulnerable older community-dwelling adults, which may reduce or the delay need for admission to LTC.

Disability Stages and Trouble Getting Needed Health Care Among Medicare Beneficiaries

OBJECTIVE

The aim of this study was to examine whether activity limitation stages were associated with patient-reported trouble getting needed health care among Medicare beneficiaries.

DESIGN

This was a population-based study (n = 35,912) of Medicare beneficiaries who participated in the Medicare Current Beneficiary Survey for years 2001-2010. Beneficiaries were classified into an activity limitation stage from 0 (no limitation) to IV (complete) derived from self-reported or proxy-reported difficulty performing activities of daily living and instrumental activities of daily living. Beneficiaries reported whether they had trouble getting health care in the subsequent year. A multivariable logistic regression model examined the association between activity limitation stages and trouble getting needed care.

RESULTS

Compared with beneficiaries with no limitations (activities of daily living stage 0), the adjusted odds ratios (ORs) (95% confidence intervals [CIs]) for stage I (mild) to stage IV (complete) for trouble getting needed health care ranged from OR = 1.53 (95% CI, 1.32-1.76) to OR = 2.86 (95% CI, 1.97-4.14). High costs (31.7%), not having enough money (31.2%), and supplies/services not covered (24.2%) were the most common reasons for reporting trouble getting needed health care.

CONCLUSION

Medicare beneficiaries at higher stages of activity limitations reported trouble getting needed health care, which was commonly attributed to financial barriers.

Perceived barriers to healthcare and receipt of recommended medical care among elderly Medicare beneficiaries

PURPOSE

Many Medicare beneficiaries perceive barriers to receiving healthcare, although the consequences are unknown. Facilitators can aid in the receipt of healthcare services. The objective was to assess the relationship between perceived facilitators and barriers to healthcare and actual receipt of recommended medical care among elderly beneficiaries.

METHODS

A cohort study using data from the 2001-2008 entry panels of the Medicare Current Beneficiary Survey that included 24,607 community-dwelling beneficiaries 65 years of age and older. Surveys elicited perceptions of healthcare with respect to: care coordination and quality; access to medical care; getting or delaying healthcare because of financial reasons; transportation; and usual source of care. The outcome was receipt of recommended medical care, expressed as an aggregate of 38 indicators covering initial evaluation, diagnostic tests, therapeutic interventions, hospitalization follow-up, and routine preventive care. Multivariable survey logistic regression produced odds ratios (ORs) and 95% confidence intervals (CIs) for receipt of recommended medical care, adjusted for sociodemographics, insurance, comorbidities, and disability.

RESULTS

Beneficiaries who reported having trouble getting or reported delaying healthcare because of financial reasons (barrier) (adjusted OR=0.79, 95% CI: 0.73-0.86) and those who reported having no usual source of care (facilitator) (adjusted OR=0.55, 95% CI: 0.48-0.63) were less likely to receive recommended medical care.

CONCLUSIONS

Survey data that capture patient perceptions of facilitators and barriers to healthcare may be useful for identifying system factors that affect timely receipt of recommended medical care. This information can inform the design of policies and programs to improve the healthcare of older adults.

Predictive Indices for Functional Improvement and Deterioration, Institutionalization, and Death Among Elderly Medicare Beneficiaries

BACKGROUND

Prediction models can help clinicians provide the best and most appropriate care to their patients and can help policy makers design services for groups at highest risk for poor outcomes.

OBJECTIVE

To develop prediction models identifying both risk factors and protective factors for functional deterioration, institutionalization, and death.

DESIGN

Cohort study using data from the Medicare Current Beneficiary Survey (MCBS).

SETTING

Community survey.

PARTICIPANTS

This study included 21,264 Medicare beneficiaries 65 years of age and older who participated in the MCBS from the 2001-2008 entry panels and were followed up for 2 years.

METHODS

The index was derived in 60% and validated in the remaining 40%. β Coefficients from a multinomial logistic regression model were used to derive points, which were added together to create scores associated with the outcome.

MAIN OUTCOME MEASURE

The outcome was activity of daily living (ADL) stage transitions over 2 years following entry into the MCBS. Beneficiaries were categorized into 1 of 4 outcome categories: stable or improved function, functional deterioration, institutionalization, or death.

RESULTS

Our model identified 16 factors for functional deterioration (age, gender, education, living arrangement, dual eligibility, proxy use, Alzheimer disease/dementia, angina pectoris/coronary heart disease, diabetes, emphysema/asthma/chronic obstructive pulmonary disease, mental/psychiatric disorder, Parkinson disease, stroke/brain hemorrhage, hearing impairment, vision impairment, and baseline ADL stage) after backward selection (P < .05). Compared to stable or improved function, the risk of functional deterioration ranged from ≤1 to ≥6, ≤4 to ≥22 for the risk of institutionalization, and ≤3 to ≥16 for the risk of death.

CONCLUSION

Predictive indices, or point and scoring systems used to predict outcomes, can identify elderly Medicare beneficiaries at risk for functional deterioration, institutionalization, and death and can aid policy makers, clinicians, and family members in improving care for older adults and supporting successful aging in the community.

LEVEL OF EVIDENCE

III.

Presence of Vision Impairment and Risk of Hospitalization among Elderly Medicare Beneficiaries

PURPOSE

To examine the association between vision impairment and all-cause hospitalization among elderly Medicare beneficiaries.

METHODS

A population-based study (N = 22,681) of community-dwelling Medicare beneficiaries aged 65 years and older who participated in the Medicare Current Beneficiary Survey for the years 2001-2007. Beneficiaries were classified into self-reported presence of vision impairment versus no vision impairment. Inpatient hospitalizations were identified using Medicare claims data. A multivariable Cox proportional hazard model examined the association between presence of vision impairment and time to first hospitalization within 3 years of survey entry after adjusting for sociodemographics, comorbidities, hearing impairment, and activity limitation stages derived from difficulty performing the activities of daily living.

RESULTS

Medicare beneficiaries who self-reported the presence of vision impairment were significantly more likely to be hospitalized over 3 years compared to beneficiaries without vision impairment even after adjustment for potentially influential covariates (hazard ratio = 1.14 and 95% confidence interval: 1.05-1.23).

CONCLUSIONS

Medicare beneficiaries with self-reported vision impairment were at higher risk of hospitalization during a 3-year period. Further research may identify reasons that are amenable to policy interventions.

Comparison of predictive value of activity limitation staging systems based on dichotomous versus trichotomous responses in the Medicare Current Beneficiary Survey

BACKGROUND

Traditional ways of measuring disability include summary indices, binary expressions, or counts of limitations. However, counts of activity of daily living (ADL) or instrumental activity of daily living (IADL) limitations do not specify which activities are limited. Activity limitation staging systems within the ADL and IADL domains depict both the severity and types of limitations experienced and specify clinically meaningful patterns of increasing difficulty with self-care.

OBJECTIVE

To compare the predictive value and utility of ADL and IADL stages based on dichotomous versus trichotomous responses to ADL and IADL questions based on "difficulty" and "receive help" responses.

METHODS

Data were analyzed from the 2005, 2006, and 2007 Medicare Current Beneficiary Survey (MCBS) entry panels on 11,706 beneficiaries. This was a prospective cohort study that examined time to inpatient admission, all-cause mortality, skilled nursing facility (SNF) admission, and long-term care (LTC) facility admission based on dichotomous versus trichotomous stages.

RESULTS

For both ADLs and IADLs, Akaike information criteria for most outcomes were lower (indicating better-performing models) for the trichotomous staging systems than the dichotomous staging systems. The hazard ratios (HRs) and 95% confidence intervals (CIs) of the dichotomous ADL staging system increased as disability increased, whereas the HRs of the other staging systems fluctuated.

CONCLUSIONS

Both staging systems have strong associations with each outcome. The dichotomous staging system is more clinically relevant while the trichotomous staging system may provide utility for clinicians, health care organizations, and policy makers seeking to predict death or admission to a hospital, SNF, or LTC facility.

The 1994-1995 National Health Interview Survey on Disability (NHIS-D): A Bibliography of 20 Years of Research

The 1994-1995 National Health Interview Survey on Disability (NHIS-D) has been one of the most unique and important data sources for studying disability, impairment, and health in the United States. In celebration of the NHIS-D's twenty-year anniversary, we created an extensive bibliography (n=212) of research that has used these data.

Patient Satisfaction and Perceived Quality of Care Among Older Adults According to Activity Limitation Stages

OBJECTIVE

To examine whether patient satisfaction and perceived quality of medical care are related to stages of activity limitations among older adults.

DESIGN

Cross-sectional study.

SETTING

Medicare Current Beneficiary Survey (MCBS) for calendar years 2001 to 2011.

PARTICIPANTS

A population-based sample (N=42,584) of persons aged ≥65 years living in the community.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

MCBS questions were categorized under 5 patient satisfaction and perceived quality dimensions: care coordination and quality, access barriers, technical skills of primary care physicians, interpersonal skills of primary care physicians, and quality of information provided by primary care physicians. Persons were classified into a stage of activity limitation (0-IV) derived from self-reported difficulty levels performing activities of daily living (ADL) and instrumental ADL.

RESULTS

Compared with older beneficiaries with no limitations at ADL stage 0, the adjusted odds ratios (ORs) for stage I (mild) to stage III (severe) for satisfaction with care coordination and quality ranged from .85 (95% confidence interval [CI], .80-.92) to .79 (95% CI, .70-.89). Compared with ADL stage 0, satisfaction with access barriers ranged from OR=.81 (95% CI, .76-.87) at stage I to a minimum of OR=.67 (95% CI, .59-.76) at stage III. Similarly, compared with older beneficiaries at ADL stage 0, perceived quality of the technical skills of their primary care physician ranged from OR=.87 (95% CI, .82-.94) at stage I to a minimum of OR=.81 (95% CI, .72-.91) at stage III.

CONCLUSIONS

Medicare beneficiaries at higher stages of activity limitation, although not necessarily the highest stage of activity limitation, reported less satisfaction with medical care.

Disability Stage is an Independent Risk Factor for Mortality in Medicare Beneficiaries Aged 65 Years and Older

BACKGROUND

Stages of activity limitation based on activities of daily living (ADLs) and instrumental activities of daily living (IADLs) have been found to predict mortality in persons aged 70 years and older but have not been examined in Medicare beneficiaries aged 65 years and older using data that are routinely collected.

OBJECTIVE

To examine the association between functional stages based on items of ADLs and IADLs with 3-year mortality in Medicare beneficiaries aged 65 years and older, accounting for baseline sociodemographics, health status, smoking, subjective health, and psychological well-being.

DESIGN

A cohort study using the Medicare Current Beneficiary Survey (MCBS) and associated health care utilization data.

SETTING

Community administered survey.

PARTICIPANTS

The study included 9698 Medicare beneficiaries aged 65 years and older who participated in the MCBS in 2005-2007.

MAIN OUTCOME MEASURES

Death within 3 years of cohort entry.

RESULTS

The overall mortality rate was 3.6 per 100 person years, and 3-year cumulative mortality was 10.3%. Unadjusted 3-year mortality was monotonically associated with both ADL stage and IADL stage. Adjusted 3-year mortality was associated with ADL and IADL stages, except that in some models the hazard ratio for stage III (which includes persons with atypical activity limitation patterns) was numerically lower than that for stage II.

CONCLUSION

We found nearly monotonic relationships between ADL and IADL stage and adjusted 3-year mortality. These findings could aid in the development of population health approaches and metrics for evaluating the success of alternative economic, social, or health policies on the longevity of older adults with activity limitations.

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.

Activity Limitation Stages empirically derived for Activities of Daily Living (ADL) and Instrumental ADL in the U.S. Adult community-dwelling Medicare population

BACKGROUND

Stages quantify severity like conventional measures but further specify the activities that people are still able to perform without difficulty.

OBJECTIVE

To develop Activity Limitation Stages for defining and monitoring groups of adult community-dwelling Medicare beneficiaries.

DESIGN

Cross-sectional.

SETTING

Community.

PARTICIPANTS

There were 14,670 respondents to the 2006 Medicare Current Beneficiary Survey.

METHODS

Stages were empirically derived for the Activities of Daily Living (ADLs) and the Instrumental Activities of Daily Living (IADLs) by profiling the distribution of performance difficulties as reported by beneficiaries or their proxies. Stage prevalence estimates were determined, and associations with demographic and health variables were examined for all community-dwelling Medicare beneficiaries.

MAIN OUTCOME MEASUREMENTS

ADL and IADL stage prevalence.

RESULTS

Stages (0-IV) define 5 groups across the separate ADL and IADL domains according to hierarchically organized profiles of retained abilities and difficulties. For example, at ADL-I, people are guaranteed to be able to eat, toilet, dress, and bathe/shower without difficulty, whereas they experience limitations getting in and out of bed or chairs and/or difficulties walking. In 2006, an estimated 6.0, 2.9, 2.2, and 0.5 million beneficiaries had mild (ADL-I), moderate (ADL-II), severe (ADL-III), and complete (ADL-IV) difficulties, respectively, with estimates for IADL stages even higher. ADL and IADL stages showed expected associations with age and health-related concepts, supporting construct validity. Stages showed the strongest associations with conditions that impair cognition.

CONCLUSIONS

Stages as aggregate measures reveal the ADLs and IADLs that people are still able to do without difficulty, along with those activities in which they report having difficulty, consequently emphasizing how groups of people with difficulties can still participate in their own lives. Over the coming decades, stages applied to populations served by vertically integrated clinical practices could facilitate large-scale planning, with the goal of maximizing personal autonomy among groups of community-dwelling people with disabilities.

Analysis of disability using WHODAS 2.0 among the middle-aged and elderly in Cinco Villas, Spain

BACKGROUND

The prevalence of disability, as defined by the International Classification of Functioning, Disability and Health (ICF), among the middle-aged and elderly population is poorly known.

OBJECTIVE

To determine disability prevalence in a resident population sample aged ≥50 years, in the Cinco Villas district, Spain, from June 2008 through June 2009.

METHODS

We used the WHODAS 2.0 36-item questionnaire to quantify the prevalence of disability, globally and by domain, together with a 13-item combined measure of three domains, Getting around, Self-care and Life activities, claimed to reflect the need of integrated services. In addition, we performed exploratory analyses of the relationship between disability and different variables using ordinal logistic regression.

RESULTS

Disability was detected by global WHODAS score in 604 of a total of 1214 persons, i.e., a prevalence of 49.8% 95% CI (46.9-52.5), with the corresponding figures for mild, moderate, severe, and extreme disability being 26.8%, 16.0%, 7.6% and 0.1%, respectively. Disability increased with age, was higher among women, and for specific domains. Prevalence of severe/extreme disability among women vs. men was as follows: Getting around, 26.8% vs. 12.1%; Life activities, 25.2% vs. 6.8%; and Self-care, 9.5% vs. 6.0%. Disability was more frequent among subjects diagnosed with dementia, chronic liver disease, severe mental disease, and stroke. The abovementioned 13-item measure yielded prevalence figures for disability levels quite similar to those obtained using 36-item scores.

CONCLUSIONS

For the first time, this study furnishes detailed disability prevalence figures and data on associated variables in a middle-aged and elderly Western population.

Prognosis for functional deterioration and functional improvement in late life among community-dwelling persons

OBJECTIVE

To examine how health-related, socioeconomic, and environmental factors combine to influence the onset of activity of daily living (ADL) limitations or prognosis for death or further functional deterioration or improvement among elderly people.

DESIGN

A national representative sample with 2-year follow-up.

SETTING

Community-dwelling people.

PARTICIPANTS

Included were 9447 persons (≥70 years of age) in the United States from the Second Longitudinal Study of Aging who were interviewed in 1994, 1995, or 1996.

METHODS

Self- or proxy-reported health conditions, ADLs expressed as 5 stages describing severity and pattern of limitations, and other baseline characteristics were obtained. A multinomial logistic regression model was used to predict stage transitions. Because of incomplete follow-up (17.7% of baseline sample), primary analyses were determined by multiple imputation to address potential bias associated with loss to follow-up.

MAIN OUTCOME MEASUREMENT

ADL stage transitions in 2 years (death, deteriorated, stable, and improved ADL function).

RESULTS

In the imputed-case analysis, the percentages for those who died, deteriorated, were stable, and improved were 12.6%, 32.7%, 48.4%, and 6.2%, respectively. Persons at a mild stage of ADL limitation were most likely to deteriorate further. Persons at advanced stages were most likely to die. Married people and high school graduates had a lower likelihood of deterioration. The risk of mortality and functional deterioration increased with age. Certain conditions, such as diabetes, were associated both with mortality and functional deterioration; other conditions, such as cancer, were associated with mortality only, and arthritis was associated only with functional deterioration.

CONCLUSIONS

Although overlap occurs, different clinical traits are associated with mortality, functional deterioration, and functional improvement. ADL stages might aid physical medicine and rehabilitation clinicians and researchers in developing and monitoring disability management strategies targeted to maintaining and enhancing self-care among community-dwelling older people.

Do elderly people at more severe activity of daily living limitation stages fall more?

OBJECTIVE

The aim of this study was to explore how activity of daily living (ADL) stages and the perception of unmet needs for home accessibility features associate with a history of falling.

DESIGN

Participants were from a nationally representative sample from the Second Longitudinal Survey of Aging conducted in 1994. The sample included 9250 community-dwelling persons 70 yrs or older. The associations of ADL stage and perception of unmet needs for home accessibility features with a history of falling within the past year (none, once, or multiple times) were explored after accounting for sociodemographic characteristics and comorbidities using a multinomial logistic regression model.

RESULTS

The adjusted relative risk of falling more than once peaked at 4.30 (95% confidence interval, 3.29-5.61) for persons with severe limitation (ADL-III) compared those with no limitation (ADL-0) then declined for those at complete limitation (ADL-IV). The adjusted relative risks of falling once and multiple times were 1.42 (95% confidence interval, 1.07-1.87) and 1.85 (95% confidence interval, 1.44-2.36), respectively, for those lacking home accessibility features.

CONCLUSIONS

Risk of falling appeared greatest for those whose homes lacked accessibility features and peaked at intermediate ADL limitation stages, presumably at a point when people have significant disabilities but sufficient function to remain partially active.

Mortality predictive indexes for the community-dwelling elderly US population

BACKGROUND

Few predictive indexes for long-term mortality have been developed for community-dwelling elderly populations. Parsimonious predictive indexes are important decision-making tools for clinicians, policy makers, and epidemiologists.

OBJECTIVE

To develop 1-, 5-, and 10-year mortality predictive indexes for nationally representative community-dwelling elderly people.

DESIGN

Cohort study.

SETTING

The Second Longitudinal Study of Aging (LSOA II).

PARTICIPANTS

Nationally representative civilian community-dwelling persons at least 70 years old. We randomly selected 60% of the sample for prediction development and used the remaining 40% for validation.

MAIN MEASURES

Sociodemographics, impairments, and medical diagnoses were collected from the LSOA II baseline interviews. Instrumental activities of daily living (IADLs) stages were derived to measure functional status. All-cause mortality was obtained from the LSOA II Linked Mortality Public-use File.

RESULTS

The analyses included 7,373 sample persons with complete data, among which mortality rates were 3.7%, 23.3%, and 49.8% for 1, 5, and 10 years, respectively. Four, eight, and ten predictors were identified for 1-, 5-, and 10-year mortality, respectively, in multiple logistic regression models to create three predictive indexes. Age, sex, coronary artery disease, and IADL stages were the most essential predictors for all three indexes. C-statistics of the three indexes were 0.72, 0.74, and 0.75 in the development cohort and 0.72, 0.72, and 0.74 in the validation cohort for 1-, 5-, and 10-year mortality, respectively. Five risk groups were defined based on the scores.

CONCLUSIONS

The 1-, 5-, and 10-year mortality indexes include parsimonious predictor sets maximizing ease of mortality prediction in community settings. Thus, they may provide valuable information for prognosis of elderly patients and guide the comparison of alternative interventions. Including IADL stage as a predictor yields simplified mortality prediction when detailed disease information is not available.

Staging activity limitation and participation restriction in elderly community-dwelling persons according to difficulties in self-care and domestic life functioning

OBJECTIVE

This study aimed to describe the conceptual foundation and development of an activity limitation and participation restriction staging system for community-dwelling people 70 yrs or older according to the severity and types of self-care (activities of daily living [ADLs]) and domestic life (instrumental ADLs (IADLs)) limitations experienced.

DESIGN

Data from the second Longitudinal Study of Aging (N = 9447) were used to develop IADL stages through the analyses of self- and proxy-reported difficulties in performing IADLs. An analysis of activity limitation profiles identified hierarchical thresholds of difficulty that defined each stage. IADL stages are combined with ADL stages to profile status for independent living.

RESULTS

IADL stages define five ordered thresholds of increasing activity limitations and a ``not relevant'' stage for those who normally have someone else do those activities. Approximately 42% of the population experience IADL limitations. To achieve a stage, a person must meet or exceed stage-specific thresholds of retained functioning defined for each activity. Combined ADL and IADL stages define 29 patterns of activity limitations expressing the individual's potential for participating in life situations pertinent to self-care and independent community life.

CONCLUSIONS

ADL and IADL stages can serve to distinguish between groups of people according to both severity and the types of limitations experienced during home or outpatient assessments, in population surveillance, and in research.

All-cause 1-, 5-, and 10-year mortality in elderly people according to activities of daily living stage

OBJECTIVES

To examine the independent association between five stages of activities of daily living (ADLs) and mortality after accounting for known diagnostic and sociodemographic risk factors.

DESIGN

For five stages of ADLs (0 to IV), determined according to the severity and pattern of ADL limitations, unadjusted life expectancies and adjusted associations with mortality were estimated using a Cox proportional hazards regression model.

SETTING

Community.

PARTICIPANTS

Nine thousand four hundred forty-seven participants aged 70 and older from the second Longitudinal Study of Aging.

MEASUREMENTS

One-, 5-, and 10-year survival and time to death.

RESULTS

Median life expectancy was 10.6 years for participants with no ADL limitations and 6.5, 5.1, 3.8, and 1.6 years for those at ADL stages I, II, III, and IV, respectively. The sociodemographic- and diagnostic-adjusted hazard of death at 1 year was five times as great at stage IV as at stage 0 (hazard ratio = 5.6, 95% confidence interval = 3.8-8.3). The associations between ADL stage and mortality declined over time but remained statistically significant at 5 and 10 years.

CONCLUSION

ADL stage continued to explain mortality risk after adjusting for known risk factors including advanced age, stroke, and cancer. ADL stages might aid clinical care planning and policy as a powerful prognostic indicator particularly of short-term mortality, improving on current ADL measures by profiling activity limitations of relevance to determining community support needs.

Prevalence and features of ICF-disability in Spain as captured by the 2008 National Disability Survey

Background

Since 1986, the study of disability in Spain has been mainly addressed by National Disability Surveys (NDSs). While international attempts to frame NDS designs within the International Classification of Functioning, Disability and Health (ICF) have progressed, in general, the ICF has hardly been used in either the NDS or epidemiological studies. This study sought to identify ICF Activity- and Participation-related content in the most recent Spanish NDS, the 2008 Survey on Disabilities, Independence and Dependency Situations (Encuesta sobre discapacidades, autonomía personal y situaciones de Dependencia - EDAD 2008), and estimate the prevalence of such ICF-framed disability.

Methods

EDAD 2008 methods and questions were perused. Of the 51 EDAD items analysed, 29 were backcoded to specific d2-d7 domains of the ICF Checklist and, by rating the recorded difficulty to perform specific tasks with or without help, these were then taken as performance and capacity respectively. A global ICF score was also derived, albeit lacking data for d1, "Learning and applying knowledge", d8, "Major Life Areas" and d9, "Community, Social and Civic Life". Data were grouped by sex, age, residence and initial positive screening, and prevalence figures were calculated by disability level both for the general population, using the originally designed weights, and for the population that had screened positive to disability. Data for institutionalised persons were processed separately.

Results

Crude prevalence of ICF severe/complete and moderate disability among the community-dwelling population aged ≥6 years was 0.9%-2.2% respectively, and that of severe/complete disability among persons living in sheltered accommodation was 0.3%.

Prevalence of severe/complete disability was: higher in women than in men, 0.8% vs. 0.4%; increased with age; and was particularly high in domains such as "Domestic Life", 3.4%, "Mobility", 1.8%, and "Self-care", 1.9%, in which prevalence decreased when measured by reference to performance. Moreover, global scores indicated that severe/complete disability in these same domains was frequent among the moderately disabled group.

Conclusions

The EDAD 2008 affords an insufficient data set to be ICF-framed when it comes to the Activity and Participation domains. Notwithstanding their unknown validity, ratings for available ICF domains may, however, be suitable for consideration under the ADL model of functional dependency, suggesting that there are approximately 500,000 persons suffering from severe/complete disability and 1,000,000 suffering from moderate disability, with half the latter being severely disabled in domains capable of benefiting from technical or personal aid. Application of EDAD data to the planning of services for regions and other subpopulations means that need for personal help must be assessed, unmet needs ascertained, and knowledge of social participation and support, particularly for the mentally ill, improved. International, WHO-supported co-operation in ICF planning and use of NDSs in Spain and other countries is needed.

Activity of daily living staging, chronic health conditions, and perceived lack of home accessibility features for elderly people living in the community

OBJECTIVE

To examine the cross-sectional associations between activity of daily living (ADL) limitation stage and specific physical and mental conditions, global perceived health, and unmet needs for home accessibility features of community-dwelling adults aged 70 and older.

DESIGN

Cross-sectional.

SETTING

Community.

PARTICIPANTS

Nine thousand four hundred forty-seven community-dwelling persons interviewed through the Second Longitudinal Study of Aging (LSOA II).

MEASUREMENTS

Six ADLs organized into five stages ranging from no difficulty (0) to unable (IV).

RESULTS

ADL stage showed strong ordered associations with perceived health, dementia severe enough to require proxy use, and history of stroke. For example, the relative risks (RRs) defined as risk of being at Stages I, II, III, or IV divided by risk of being at Stage 0 for those with dementia ranged from 3.2 (95% confidence interval (CI)=2.4-4.4) to 41.9 (95% CI=19.6-89.6) times the RRs for those without dementia. The RR ratios (RRR) comparing respondents who perceived unmet need for accessibility features in the home to those without these perceptions peaked at Stage III (RRR=17.8, 95% CI=13.0-24.5) and then declined at Stage IV. All models were adjusted for age, sex, and race.

CONCLUSIONS

ADL stages showed clinically logical associations with other health-related concepts, supporting external validity. Findings suggest that specificity of chronic conditions will be important in developing strategies for disability reduction. People with partial rather than complete ADL limitation appeared most vulnerable to unmet needs for home accessibility features.

Blending activity and participation sub-domains of the ICF

OBJECTIVE

The objective of the study was to test the supposition that distinct Activity and Participation sub-domains of the International Classification of Functioning, Disability, and Health (ICF) could be identified using physical function questionnaire items drawn from the Activity and Participation Measures for Post Acute Care.

DESIGN

A cross-sectional survey design was employed. Subjects. The sample consisted of 272 patients who had received post acute care across inpatient and community care settings during the previous year.

METHODS

Exploratory factor analysis with oblique rotation was used to identify interpretable dimensions underlying 83 physical functioning questionnaire items.

RESULTS

Factor analysis findings revealed five distinct ICF conceptual sub-domains that explained 61% of the total variance of the data, with root mean square residual equal to 0.089. These domains were labeled: (i) Daily activity, (ii) Applied cognitive, (iii) Role participation, (iv) Mobility, and (v) Social participation. These five factors were correlated to varying degrees and achieved acceptable levels of internal consistency with coefficient alphas from 0.59-0.93.

CONCLUSION

These analyses suggest that clear distinctions between Activity and Participation sub-domains of the ICF could not be identified in a sample of adults who had recently received post acute care. We believe this is important evidence of the ability to measure blended Activity and Participation sub-domains that cut across distinct and interpretable areas of life functioning.

Assessing self-care component of activities and participation domain of the international classification of functioning, disability and health (ICF) among people living with HIV/AIDS

Disability experience of persons with HIV illness has shifted from issues related to physical well-being to those concerning performance of daily life activities. This study aimed to find out the nature of self-care among people living with HIV/AIDS (PLWHA) in rural tertiary care center. The objectives were to determine reported self-care by performance qualifier of PLWHA and to find out reported self-care by capacity qualifier of PLHIV. A cross sectional study was conducted among the 194 PLHIV in rural tertiary care hospital. The Self-Care (d5) component of Activities and Participation domain (d) of the International Classification of Functioning, Disability and Health (ICF) was used. Among the 194 PLHIV patients studied, 82% were male. The average age was 36.87 years (SD+/-9.01) with a median of 35 years, varying from 15 to 65 years. Over 65% of the study group experienced one or more impairments. As HIV disease has become a more lifelong, unpredictable, but medically manageable condition, there is a need for more collaboration with other disability groups in order to identify commonalities in their experiences and to share collective concerns.