Aging with a disability 11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors(s) or upon any organization with which the author(s) is/are associated

Aging with long-term physical disability: Cohort analysis of survey sample in the U.S

Background

Chronic health conditions, secondary conditions, and decreasing functional ability related to aging and/or changes in underlying impairment may influence participation for persons aging with long-term physical disability (AwD).

Objective

To examine sample integrity and baseline findings through exploration of associations of sociodemographic, health, and disability factors with social participation for persons AwD.

Methods

This is a longitudinal cohort study following persons AwD over three years, reporting baseline cohort study data. A convenience sample of 474 persons AwD aged 45-65 reporting physical disability of ≥5 years' duration was recruited through community organizations and social media. The cohort was majority female (66.7%) and single (62.0%), and over one-third (38.6%) was non-White. Pain, fatigue, depression, ability to participate in, and satisfaction with, social roles and activities were measured with the Patient Reported Outcomes Measurement Information System. Results were manually compared against AwD study samples identified through a focused literature review and national census data.

Results

Participants aged 55-60 and 61-65 had significantly lower rates of employment and marriage and higher rates of living alone than participants aged 45-54. Participants reported higher rates of fatigue, pain, and depression and lower ability to participate in, and satisfaction with, participation in, social roles and activities than the general population. Ability to participate and satisfaction with participation were highest among Black/African American participants.

Conclusions

Participants reported higher rates of common AwD symptoms and lower ability to participate and satisfaction with participation than the general population, consistent with prior studies of AwD samples. This cohort reflects the AwD population and can be considered an AwD sample, comparable to those found in existing literature. The focus of future analyses will be to gain a greater understanding of chronic health conditions, incidence of falls, engagement in everyday life activities, and the impact of the environment.

Aging with long-term physical disability: Cohort analysis of survey sample in the U.S

BACKGROUND

Chronic health conditions, secondary conditions, and decreasing functional ability related to aging and/or changes in underlying impairment may influence participation for persons aging with long-term physical disability (AwD).

OBJECTIVE

To examine sample integrity and baseline findings through exploration of associations of sociodemographic, health, and disability factors with social participation for persons AwD.

METHODS

This is a longitudinal cohort study following persons AwD over three years, reporting baseline cohort study data. A convenience sample of 474 persons AwD aged 45-65 reporting physical disability of ≥5 years' duration was recruited through community organizations and social media. The cohort was majority female (66.7%) and single (62.0%), and over one-third (38.6%) was non-White. Pain, fatigue, depression, ability to participate in, and satisfaction with, social roles and activities were measured with the Patient Reported Outcomes Measurement Information System. Results were manually compared against AwD study samples identified through a focused literature review and national census data.

RESULTS

Participants aged 55-60 and 61-65 had significantly lower rates of employment and marriage and higher rates of living alone than participants aged 45-54. Participants reported higher rates of fatigue, pain, and depression and lower ability to participate in, and satisfaction with, participation in, social roles and activities than the general population. Ability to participate and satisfaction with participation were highest among Black/African American participants.

CONCLUSIONS

Participants reported higher rates of common AwD symptoms and lower ability to participate and satisfaction with participation than the general population, consistent with prior studies of AwD samples. This cohort reflects the AwD population and can be considered an AwD sample, comparable to those found in existing literature. The focus of future analyses will be to gain a greater understanding of chronic health conditions, incidence of falls, engagement in everyday life activities, and the impact of the environment.

Impairments and comorbidities in adults with cerebral palsy and spina bifida: a meta-analysis

Introduction

Aging with a childhood-onset disability, such as cerebral palsy (CP), spina bifida (SB), and muscular diseases (MD), comes along with significant impairments and comorbidities. Despite the increasing evidence an overall picture is lacking. This study aimed to review the literature about adults with CP/SB/MD and impairments and comorbidities to perform a meta-analysis.

Materials and methods

Embase, PubMed, Cinahl, and Google Scholar were searched (2000-2020). Search terms included adults with one of the aforementioned disabilities combined with impairments and comorbidities. If specific impairments or comorbidities were reported by at least four studies, these were included in the study. Pooled prevalence (95% Confidence Interval) of impairments/comorbidities were calculated.

Results

The search yielded 7,054 studies of which 95 were included in the meta-analysis (64 CP, 31 SB, 0 MD). In total estimates were calculated for 26 (CP) and 11 (SB) outcomes. In adults with CP, pain [56.4% (95%CI 48.8-63.8)], deformities [44.2% (95%CI 12.9-78.4)], intellectual disability [37.2% (95%CI 26.7-48.3)], and fatigue [36.9% (95%CI 24.6-50.1)] were most prevalent; renal disease [3.0% (95%CI 2.1-4.2)] and stroke/rheumatic diseases {4.8% (95%CI 3.4-6.5; 4.8% (95%CI 1.5-9.9)] respectively} were least prevalent. For adults with SB, bladder incontinence [60.0% (95%CI 50.5-69.2)], bowel incontinence [49.2% (95%CI 34.5-64.0)], pain [44.1% (95%CI 27.4-61.5)], and sleeping problems [30.3% (95%CI 4.7-65.8)] were most prevalent; diabetes [4.8% (95%CI 2.8-7.3)] and renal disease [8.7% (95%CI 2.0-19.9)] were least prevalent. The included studies showed large heterogeneity.

Conclusions

More research is needed to study health issues in adults with MD. Adults with CP or SB deal with a variety of health issues. More attention for the mental health of these adults is needed. There also is a need for accessible and adequate screening, preventive measures and clinical follow-up.

Interventions to promote independent participation among community-dwelling middle-aged adults with long-term physical disabilities: a systematic review

PURPOSE

People aging with long-term physical disabilities (PAwLTPD) are aging at an accelerated rate beginning in middle-age. They face age-related challenges in conjunction with their existing disabilities; thus, maintaining independence as they age is often difficult. The aim of this systematic review was to examine the effectiveness of rehabilitation interventions for middle-aged PAwLTPD to participate independently in the home and community.

MATERIALS AND METHODS

We searched four databases - MEDLINE, CINAHL, Web of Science, and EMBASE - for studies published from January 2005 to December 2020. Information from included studies was extracted using a critical appraisal form. Studies were categorized based on common themes, assigned level of evidence, and assessed for risk of bias.

RESULTS

Fourteen articles were included. Common themes derived were fall risk reduction, functional capacity, community mobility, and function within the home. The strongest evidence supports wheelchair skills training programs (WSTPs) among manual wheelchair users and targeted paretic limb exercise post-stroke. Moderate evidence supports exercise and multicomponent interventions for those with multiple sclerosis, adaptive strategy training and WSTPs to improve satisfaction with mobility for power wheelchair users, and home modifications/assistive technology for mobility-impaired individuals.

CONCLUSION

Interventions with strong and moderate evidence should be routinely offered for middle-aged PAwLTPD. Future research should focus on developing evidence-based interventions for middle-aged PAwLTPD.IMPLICATIONS FOR REHABILITATIONMiddle-aged PAwLTPD face the same aging-related challenges as people without disabilities but will experience additional difficulties due to compounding effects of long-term health conditions and aging.Current effective interventions to promote participation for middle-aged PAwLTPD have been measured over a wide range of outcomes, and many interventions should be used by clinicians on a case-by-case basis.Wheelchair skills training was found to have the strongest evidence and is recommended for use with middle-aged PAwLTPD who use manual and power wheelchairs.

Establishing Content Validity Evidence of the Pittsburgh Impairment Testing Tool (PITT) for Adults With Spina Bifida

Background

Current scales to measure motor impairment in adults with spina bifida (SB) are limited by their complexity, variable interpretation (i.e., subjectively defined impairment levels), or inclusion of muscles groups that are not always practical to test in a clinical setting.

Objectives

A novel motor impairment tool for adults with SB was evaluated for content validity. The tool uses findings from the manual muscle testing of hip flexion and knee extension to categorize individuals into four motor impairment groups.

Methods

Expert feedback was obtained on the tool, and content validity was measured using Lawshe's content validity ratio (CVR) with critical values recommended by Ayre and Scally. Data from phase 1 and phase 2 were used to revise the survey and calculate the CVR of the tool, respectively (benchmark: CVR ≥ 0.636).

Results

Of the 26 experts recruited, 17 received the survey and 15 participated in either phase 1 (n = 6) or 2 (n = 11). The CVR values for each impairment group were as follows: intact strength (0.95), thoracic strength (0.90), hip flexor dominant strength (0.89), and knee extensor dominant strength (0.82). The CVR of the tool overall was 0.89. Qualitative expert feedback revealed common barriers to manual muscle testing and suggestions for improving the tool. However, experts also noted the value in preserving the simplicity of the tool.

Conclusion

The high content validity, coupled with expert feedback, suggests the tool may give clinicians and researchers a practical method of classifying an individual's extent of motor impairment.

Serum Concentrations of Thyroid-Stimulating Hormone, Triiodothyronine, and Thyroxine in Outpatients Infected with SARS-CoV2 in Khuzestan Province, Iran: A Disease Clinical Course Approach

Background and Objectives: The virus SARS-CoV2, which causes COVID-19, affects the endocrine system. This study investigated serum concentrations of the thyroid-stimulating hormone (TSH), triiodothyronine (T3), and thyroxine (T4) in 53 outpatients infected with SARS-CoV2 and 53 non-infected matched participants in Khuzestan Province, Iran. We also examined the possible association of clinical symptoms progression and disease severity with serum concentrations of TSH, T3, and T4. Materials and Methods: A checklist was applied to collect demographic and clinical data. Blood samples were taken for biochemical analysis of serum concentrations of TSH, T3, and T4. Clinical symptoms of the infected outpatients were monitored weekly for 28 days. Results: Our results indicated that, as the severity of the disease increased, the respiratory and pulse rates raised significantly. Additionally, disease severity was significantly different between genders. Specifically, 79.5% of the asymptomatic/mild, and 38.5% of moderate outpatients were men. We also found significantly lower serum T3 but higher T4 in infected outpatients, compared with controls. However, serum TSH did not significantly differ between the two groups. The generalized estimating equation (GEE) analysis revealed no relationship between clinical symptoms progression and disease severity with serum concentrations of TSH, T3, and T4 in our study population. Additionally, GEE analysis showed that the odds ratio of neurological symptoms among women was 2.5 times that of men, the odds ratio of neurological symptoms in illiterates was 10 times higher than that of those without a high-school diploma, and the chance of developing pulmonary symptoms in those without high-school diploma was about 21 times higher than illiterates. Conclusion: In conclusion, this study showed that infected outpatients had significantly lower serum T3 but higher T4 than non-infected participants. There was no relation between symptom progression and disease severity with serum concentrations of TSH, T3, and T4, but educational status and sex significantly affected the chance of neurological and pulmonary symptoms occurring over 28 days. Our results may be used to develop potential therapies to treat COVID-19 disease.

Ageing with neuromuscular disease: Implications for a lifeworld-led care through a humanising approach

OBJECTIVES

To understand the care and support needs in ageing with neuromuscular disease from a patient-user perspective.

BACKGROUND

The term neuromuscular disease covers several chronic hereditary or acquired disease subtypes. In the developed countries, advances in symptoms management, technical advancements and rehabilitation initiatives have resulted in increased life expectancy for some subtypes. Life with neuromuscular disease is thus likely to continue into adulthood and old age. However, knowledge of the care and support needs of patients ageing with neuromuscular disease remains sparse.

DESIGN

Adopting a user-participatory approach embedded in a phenomenological hermeneutic tradition, we conducted two user-group discussions focusing on care and support needs in people ageing with neuromuscular disease. Twenty-five users with neuromuscular disease participated in the group discussions. Data were analysed using a three-stepped analysis method inspired by the French Philosopher Paul Ricoeur. In the analysis process, dialectical movements between a surface interpretation and an in-depth understanding occur. The COREQ checklist was used to report the study.

RESULTS

Two themes were identified; 'Changes in the sheltering relationships of life require preparation' and 'Ageing introduces a dichotomy between circumstantial normalcy and minority groupness'. An understanding of care and support needs in life with neuromuscular disease was reached revealing a need for a lifeworld-led approach.

CONCLUSION

Persons ageing with neuromuscular disease crave a fusion of disease- and age-led care and support. This fusion may be achieved through the introduction of a lifeworld-led approach to care and support.

RELEVANCE FOR CLINICAL PRACTICE

Unmet care and support needs in people ageing with neuromuscular disease may result in patients experiencing fear and concern about their life situation. Healthcare professionals may play a crucial role in creating coherent lives for these persons if they understand the approach proposed herein to uncover the care and support needs in people ageing with neuromuscular disease.

Participation amongst people ageing with neuromuscular disease: a qualitative study of lived experiences

Aim

To explore the lived experiences of participation in everyday life ageing with neuromuscular disease (NMD).

Design

A qualitative study using a phenomenological‐hermeneutic approach.

Methods

Data were gathered through interviews with 15 persons living with NMD in 2018. A three‐levelled analysis and interpretation influenced by Paul Ricoeur's philosophy were conducted.

The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was used from May 2018 to December 2018.

Results

Three themes were identified: “Endless adaptations change the fundamentals of everyday life ageing with NMD,” “The ‘swamp’ of deterioration” is traversed through experiences of belonging and relationship,” “Being disabled by a professional knowledge gap and stereotypical images.” In these themes, the experience of participation in everyday life ageing with NMD appeared to depend on the ability to adapt constantly. Through participation, a sense of belonging and purpose was maintained. Lack of knowledge amongst professionals may negatively affect the ongoing participation of people ageing with NMD.

Ageing with neuromuscular disease: getting lost in transitions

PURPOSE

To explore the lived experiences of people ageing with neuromuscular disease (NMD).

INTRODUCTION

NMD refers to several chronic types of hereditary and progressive NMDs. Owing to advances in rehabilitation and treatment, life expectancy has increased for some subtypes, resulting in life continuing into adulthood and even old age; however, knowledge of people's lived experiences with NMD is sparse.

METHODS

A qualitative study using a phenomenological-hermeneutic approach inspired by Ricoeur was conducted. Fifteen persons with NMD were interviewed in 2018. The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was used.

RESULTS

Four themes were identified: "A time-framed paradox of striving for independent dependency arises as age increases", "Ageing means entering no man's land", "Exercising is caught between shrinking surplus of physical energy and demands of everyday life" and "Ending work life is a jumble of relief, concern and altered self-perception".

CONCLUSION

The pathway to old age with NMD encompasses several transitions, all potentially including the risk of getting lost. Physical changes, changes in legislation, experiences of uncertainty regarding where one socially belongs and how to balance reduced physical strength in everyday life are indicated as key areas that affect ageing life with NMD.Implications for rehabilitationRehabilitation professionals should address ageing with NMD from a life course perspective and not with a singled minded focus on chronological age.A biopsychosocial focus is needed to prevent gaps and pave the pathway to old age with NMD.The experiences of multiple transitions when ageing with NMD should be in focus.

Using Facebook to tell stories of premature ageing and sexual and reproductive healthcare across the life course for women with cerebral palsy in the UK and USA

OBJECTIVE

To enhance understanding of the bodily and lifestyle effects of ageing with cerebral palsy (CP) for women, with a particular focus on experiences with sexual and reproductive healthcare (SRH) services in the UK and North America.

DESIGN

A qualitative study underpinned by feminist disability theory and drawing on digital ethnographies to capture health and healthcare experiences for women with CP.

SETTING

A global community of 140 women with CP, who are members of the closed international Facebook group, Women Ageing with Cerebral Palsy (WACP).

PARTICIPANTS

Forty-five members of WACP who were based in the UK and North America. The women were aged between 21 and 75.

METHODS

Messages posted on WACP between January 2018 and October 2018 were collated and underwent thematic analysis to identify themes relating to effects of ageing and experiences of SRH for women with CP at different points over the female life course.

RESULTS

The breadth of experiences in relation to the effects of ageing and access to reproductive and sexual healthcare for women with CP can be divided into three themes: (1) bodily effects of ageing; (2) lifestyle effects of ageing; (3) experiences of reproductive and sexual healthcare.

CONCLUSIONS

Giving women with CP a platform to 'speak for themselves' in relation to effects of ageing and SRH provides health professionals with an informed knowledge base on which to draw. This might improve treatment for this growing adult patient community whose experiences have not received attention in health discourse or services. Including these experiences in public medical and social discourse can also bring a new knowledge to girls with CP about what ageing could mean for them so plans can be put in place for their future.

Impact of secondary health conditions on social role participation for a long-term physical disability cohort

For people living with long-term physical disability (LTPD) social participation may involve managing physical impairments and secondary health conditions (SHCs) that are not due to the pathophysiology of the LTPD diagnosis itself. Prior research found a negative relationship between SHCs and participation in social roles in people with spinal cord injury (SCI). We expand on this research by investigating the influence of SHCs on participation in social roles for people with one of four LTPDs, controlling for co-variates. We (1) evaluated the associations between SHCs and participation in social roles; and (2) determined whether SHCs on individuals' ability to participate in social roles varies by type of diagnosis in those aging with either SCI, muscular sclerosis, muscular dystrophy, or post-polio syndrome. Cross-sectional, secondary data analysis from a return-by-mail survey. N = 1,573. Data were analyzed with multiple linear regressions (hypothesis 1), and then three moderated regressions (hypothesis 2). After controlling for demographics, SHCs were associated with lower ability to participate in social roles and accounted for 48% of the variance (all p's <.001). The relationship between depression and social role participation was moderated by diagnosis, such that depression was more negatively associated with social participation among individuals with SCI (p = .020). Thus, SHC negatively impact participation in social roles.

The health and quality of life of Thalidomide survivors as they age - Evidence from a UK survey

Background

In the late 1950s and early 1960s the drug Thalidomide was marketed across the world as a non-addictive tranquilizer. Despite being given to pregnant women as a safe treatment for morning sickness, Thalidomide caused serious damage to the unborn child. Much has been written about the drug and the birth defects it caused but evidence about the health of Thalidomide survivors as they age is limited.

Aim

The aim of this study was to: explore the health and wellbeing UK Thalidomide survivors; document the health problems experienced by them as they reach their mid-50s; and examine the impacts on their health-related quality of life and employment.

Methods

A health and wellbeing survey of 351 UK Thalidomide survivors, which gathered information about home and employment circumstances, recent health problems, and health related quality of life (using SF12 Health Survey). Overall analysis focused on descriptive statistics; the association between respondents’ health related quality of life and original impairment was examined using Pearson Correlation; and a three step Hierarchical Regression was used to explore the influence of five factors which narrative responses suggested might be important.

Results

As Thalidomide survivors reach their mid-50’s they are experiencing a wide range of secondary health problems, in particular musculoskeletal problems, and depression and anxiety, with multimorbidity a growing issue. These health problems are having a negative impact on their employment (two fifths are unable to work) and their physical health related quality of life, which is significantly poorer than the general population.

Discussion

Having lived relatively independent lives, many Thalidomide survivors are now having to adjust to growing disability. The study provides further evidence of the accumulative impact of disability over peoples’ lifetimes and highlights the value of a life course perspective in understanding the complex experience of growing older with a disability.

Health Service Utilization and State Costs Among Adults Aging With Early-Acquired Physical Disabilities in Medicaid Managed Care

Objective: We evaluated the impact of Medicaid managed care (MMC) on health service use and state costs among adults with early-acquired physical disabilities. Method: Using claims data, we tracked utilization of the emergency department (ED), inpatient admissions, outpatient physician visits, and state expenditures on enrollees who transitioned to MMC (n = 881). The inverse propensity score weight and a difference-in-differences regression model were used to estimate the impact of MMC using their counterparts who remained in fee-for-service (n = 1,552) as the comparison group. Results: MMC reduced ED use by 3.2% points/month (p < .001). Relative to younger enrollees (age ⩽45 years), MMC reduced inpatient admissions of older enrollees (age ⩾46 years) by 3.3% points/month (p < .001), and state expenditures by US$839/month (p < .01). Discussion: MMC could reduce the hospital service use of and state spending on enrollees with early-acquired physical disabilities. This impact may vary depending on the enrollees' age.

The changing health of Thalidomide survivors as they age: A scoping review

BACKGROUND

In the late 1950s and early 1960s the drug Thalidomide was given to thousands of pregnant women across the world to relieve morning sickness. The drug caused severe birth defects. Much has been written about the drug, its teratogenic effects, and the nature of the damage it caused. There is however, little literature exploring ageing with Thalidomide damage.

OBJECTIVES

The aim of the review was to bring together, for the first time, the evidence about the Thalidomide-related health problems Thalidomide survivors are experiencing, as they grow older.

METHODS

A systematised review of published and grey literature, in which grounded theory provided a heuristic for the evidence synthesis.

RESULTS

Twenty-five relevant papers were found. They included biomedical papers focusing on specific health problems, alongside surveys and mixed method accounts exploring the health of Thalidomide survivors. Most studies had physical health as their primary focus.

CONCLUSIONS

The two most frequently reported groups of health problems were musculoskeletal and mental health conditions. There was little discussion about the social consequences of secondary damage being layered onto lifelong impairments or of the implications of co-morbidities. Future research needs a stronger connection to more social models of disability and critical disability studies.

Envejecimiento en parálisis cerebral, un reto en investigación e innovación: revisión sistemática

Apenas existen iniciativas de investigación en el ámbito del envejecimiento activo y saludable de las personas con parálisis cerebral. Encontrar soluciones a este reto social requiere una red de excelencia en investigación que contribuya a vivir mejor a toda la sociedad. Se recopiló información sobre parálisis cerebral y envejecimiento concretamente sobre necesidades percibidas, calidad de vida y repercusión del envejecimiento en las personas con parálisis cerebral. Se revisaron los conceptos que constituyen el marco teórico para investigar. A continuación se analizó la literatura encontrada sobre el proceso de envejecimiento. Por último se recogieron atendiendo a los principios de igualdad de oportunidades, no discriminación y accesibilidad universal, líneas de actuación a tener en cuenta por los investigadores en el desarrollo de actividades innovadoras. Invertir en investigación e innovación es esencial para el futuro, es la manera de impulsar productos y servicios y así crear una sociedad mejor para todos los ciudadanos.

Reducing the Shared Burden of Chronic Conditions among Persons Aging with Disability and Older Adults in the United States through Bridging Aging and Disability

Persons aging with long-term disabilities such as spinal cord injury or multiple sclerosis and older adults share similar chronic conditions in mid and later life in the United States. The rising general interest and more prevalent federal requirements for use of evidence-based practices (EBP) in health promotion and chronic condition interventions highlight the gap between demand and the availability of EBPs for persons aging with disability in particular. Addressing this gap will require focused efforts that will benefit substantially by bridging the fields of aging and disability/rehabilitation to develop new EBPs, translate existing EBPs across populations, and borrow best practices across fields where there are few current EBPs. Understanding distinctions between disability-related secondary conditions and age-related chronic conditions is a first step in identifying shared conditions that are important to address for both mid-life and older adults with disabilities. This review articulates these distinctions, describes shared conditions, and discusses the current lack of EBPs for both populations. It also provides recommendations for bridging activities in the United States by researchers, professionals, and consumer advocates. We argue that these can more efficiently move research and practice than if activities were undertaken separately in each field (aging and disability/rehabilitation).

Long-Term Deterioration of Perceived Health and Functioning in Adults With Cerebral Palsy

OBJECTIVE

To describe longitudinal change in perceived health, presence of health issues, and functional level in adults with cerebral palsy (CP).

DESIGN

Prospective cohort study.

SETTING

Participants' daily environment.

PARTICIPANTS

Adults (N=49) with CP (age range, 35-45y; 27 [55%] men; 36 [75%] spastic) formerly known in pediatric rehabilitation care participated.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Postal questionnaires were completed by the adults or their proxies (n=9). Health outcomes included perceived health (adapted from the 36-Item Short Form Health Survey) and presence of health issues such as pain, severe fatigue (dichotomized), and functional level (Barthel Index; walking performance).

RESULTS

Over a 10-year period, the percentage of adults with CP worrying about their health increased (29%-54%; P=.008) and those indicating that health problems limit their activities increased (19%-45%; P=.002). In the same period, most adults continued to report good general health (93%-86%; P=.148). Presence of some health issues increased over time, such as pain; severe fatigue was a common health issue at follow-up (32%). Over a 14-year period, mobility and self-care deteriorated (Barthel Index, 17.1±4.8 to 16.3±5.6; P=.007). Walking performance, specifically indoors, declined (83%-71%; P=.010).

CONCLUSIONS

Adults with CP experienced deterioration in health outcomes in the long term. Most notably, perceived health and functional level decreased. Pain and severe fatigue were the most common health issues in adult CP. More research is required to explore the mechanisms at work in the process of aging in persons with CP. Systematic follow-up of adults with CP appears necessary to timely detect and intervene in health problems and functional decline.

Aging With Disability for Midlife and Older Adults

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

Health and participation problems in older adults with long-term disability

BACKGROUND

More attention and understanding of the health and participation problems of adults with early and later onset disabilities in the Netherlands is needed.

OBJECTIVE

To explore health/participation problems and unmet needs in adults aged ≥40 years with long-term disabilities and their relationship with the time of onset.

METHODS

Participants were recruited in the Netherlands through newsletters and social media to participate in a web-based questionnaire. The questionnaire assessed background characteristics, (change in) health/participation problems, and unmet needs. Spearman's rho was used to examine the relationships with time of onset.

RESULTS

Of the 163 survey respondents, 42% acquired their disability before age 25 years and reported fatigue (77%), walking problems (66%), and pain (59%). In 21% of the respondents with early-onset disability fatigue, pain and depressive feelings co-occurred. Early-onset disability correlated with joint deformities, pain and anxiety. Participation problems included loss of income and fewer social activities. Early-onset correlated with the need for more information about diagnosis and prognosis.

CONCLUSIONS

People aged over 40 years with long-term disability have significant and increasing health and participation problems. Adults with early-onset disability are more likely to have health or participation problems than adults with late-onset disability. Early identification is needed for preventive care and access to specialized services that focus on improving and maintaining physical symptoms, energy management, and participation.

Communication changes experienced by adults with cerebral palsy as they age

PURPOSE

Adults with cerebral palsy (CP) experience multiple, functional changes as they age, including changes to communication modes and methods that enable development and maintenance of relationships, communicative participation and quality-of-life. Little is known about the nature of communication changes experienced by this group. The aim of this study was to better understand how adults with CP experience changes in their communication abilities as they age and the subsequent psychosocial impact.

METHOD

Twenty adults with cerebral palsy aged 40-72 years with complex communication needs (CCN) participated in a series of in-depth interviews, framing their experiences of loss and grief throughout their lives. The impact of changing communication abilities emerged as an important area of focus. Data were analysed using constructivist grounded theory methodology.

RESULT

Themes arising from the participants' perceptions of their communication included experiencing communication change as a loss with subsequent impact on self-concept; and how communication is integral to the process of managing losses associated with older age.

CONCLUSION

Implications for speech-language pathologists working with older people with cerebral palsy and CCN include the need to understand the psychosocial impact of communication changes on social interaction, relationships and communicative participation. It is important to promote positive and meaningful communication options that maintain a coherent sense of self in addition to promoting functional communication skills and communicative participation.

Portuguese cultural adaptation and validation of the Activities Scale for Kids (ASK)

OBJECTIVES

The main purpose of the current study was to perform the cross cultural adaptation and validation of the Activities Scale for Kids (ASK) both in its capability and performance versions to the European Portuguese language so it can be used in Portugal by healthcare professionals in children from 5 to 15 years of age with functional disabilities related to specific health conditions.

METHODS

The cross-cultural adaptation of ASK followed the classic sequential methodology for linguistic equivalence. To test its validity, internal consistency, and reproducibility, the Portuguese version of ASK was administered together with the KINDL Questionnaire (KINDL) to 88 children (10±3 years of age) with functional limitations. The test-retest study was conducted two weeks apart.

RESULTS

After obtaining the semantic and content validity, the Portuguese version of ASK demonstrated good levels of reproducibility (performance: intraclass correlation coefficient [ICC]=0.99; capability: ICC=0.98) and internal consistency (performance: α=0.98; capability: α=0.97). The correlations between ASK and KINDL were positive and moderate.

CONCLUSIONS

The Portuguese version of ASK showed acceptable levels of validity, internal consistency, and reproducibility; the authors recommend its use in clinical settings.

Long-Term Predictors of Social and Leisure Activity 10 Years after Stroke

Background

Restrictions in social and leisure activity can have negative consequences for the health and well-being of stroke survivors. To support the growing number of people who are ageing with stroke, knowledge is needed about factors that influence such activity in a long-term perspective.

Aim

To identify long-term predictors of the frequency of social and leisure activities 10 years after stroke.

Method

145 stroke survivors in Sweden were followed-up at16 months and 10 years after a first-ever stroke. Data representing body functions, activities & participation, environmental factors and personal factors at 16 months after stroke, were used in multiple linear regression analyses to identify predictors of the activity frequency after 10 years, as assessed by the ‘Community, social and civic life’ sub-domain of the Frenchay Activities Index (FAI-CSC).

Results

At the 10-year follow-up the frequency of social and leisure activities varied considerably among the participants, with FAI-CSC scores spanning the entire score range 0–9 (mean/median 4.9/5.0). Several factors at 16 months post stroke were independently related to the long-term activity frequency. The final regression model included four significant explanatory variables. Driving a car (B = 0.999), ability to walk a few hundred meters (B = 1.698) and extent of social network (B = 1.235) had a positive effect on activity frequency, whereas an age ≥ 75 years had a negative effect (B = -1.657). This model explained 36.9% of the variance in the FAI-CSC (p<0.001).

Conclusion

Stroke survivors who drive a car, have the ability to walk a few hundred meters and have a wide social network at 16 months after a first-ever stroke are more likely to have a high frequency of social and leisure activities after 10 years, indicating that supporting outdoor mobility and social anchorage of stroke survivors during rehabilitation is important to counteract long-term inactivity.

The "long arm" of childhood health: linking childhood disability to late midlife mental health

A growing body of research underscores the early origins of health in later life; however, relatively little is known about the relationship between childhood physical health and adult mental health. This research explores the relationship between childhood disability and depressive symptoms among a nationally representative sample of late midlife adults (N = 3,572). Using data from Waves 8-10 (2006-2010) of the Health and Retirement Study, a series of ordinary least squares regression models were created to assess the number of depressive symptoms. Childhood disability was significantly associated with higher levels of depressive symptoms; however, late midlife social and health factors accounted for differences between those with and without childhood disability. Late midlife physical health appeared to be a particularly salient mediator. Individuals who experience childhood disability may accumulate more physical impairment over the life course, thus experiencing worse mental health such as greater depressive symptoms in late midlife.

Identifying factors associated with changes in physical functioning in an older population

AIM

The present study evaluated the association between changes in physical functioning and a variety of factors in an older population in Taiwan.

METHODS

The data of 907 participants were derived from a three-wave cohort study of aging, the Functioning and Aging Study in Taipei, with a study period from 2005 to 2009. Functional status was assessed using activities of daily living, instrumental activities of daily living and mobility tasks, and classified as being normal, with mild disability, moderate disability, and severe disability. All potential factors were allocated into five groups including demography, chronic diseases, geriatric conditions, lifestyle and physical assessments. Generalized estimating equations and generalized linear mixed-effects models were used to identify factors responsible for changes in physical functioning across different waves of data.

RESULTS

The proportion of elderly participants with normal function decreased with time throughout the study period. The results of Generalized estimating equations and mixed effects models showed nearly identical sets of factors. These included age, living arrangements, social support, self-rated health, stroke, diabetes, Parkinson's disease, osteoporosis, depression, cognition, vision, history of fracture and falls, incontinence of urine and feces, physical activity, body mass index, and short physical performance battery.

CONCLUSIONS

Older persons with stroke, Parkinson's disease, diabetes, osteoporosis, geriatric conditions and poor short physical performance battery score should be considered as the target of prevention against functional decline. Those not living with spouses, with poor self-rated health, with low social support, being underweight or obese and with a sedentary lifestyle might also require major attention.

The potential for technology to enhance independence for those aging with a disability

Technologies of all kinds can sustain and accelerate improvements in health and quality of life for an aging population, and enhance the independence of persons with disabilities. Assistive technologies are widely used to promote independent functioning, but the aging of users and their devices produces unique challenges to individuals, their families, and the health care system. The emergence of new "smart" technologies that integrate information technology with assistive technologies has opened a portal to the development of increasingly powerful, individualized tools to assist individuals with disabilities to meet their needs. Yet, issues of access and usability remain to be solved for their usefulness to be fully realized. New cohorts aging with disabilities will have more resources and more experience with integrated technologies than current elders. Attention to technological solutions that help them adapt to the challenges of later life is needed to improve quality of life for those living long lives with disabilities.

Outcome and life satisfaction of adults with myelomeningocele

BACKGROUND

Myelomeningocele (MMC) commonly causes impairments in body structure and functions as well as cognitive disabilities that can have an adverse effect on adult life. Improved medical care has resulted in increased numbers of individuals with MMC surviving to adulthood, however little is known about the impact of MMC on the lives of adults age 25 years or older.

OBJECTIVE

To gain a better understanding of outcomes in education, employment, relationships, reproduction and life satisfaction of adults with MMC.

METHODS

A primarily quantitative multiple-choice questionnaire designed to capture outcomes in education, employment, relationships and reproduction, along with a previously validated life satisfaction checklist (LiSat-11), was completed by adults with MMC. Relationships between demographic variables, outcomes and life satisfaction were determined using cross tabulation analysis, logistic regression and linear regression.

RESULTS

Ninety adults with MMC, age 25-85 years (median age 32), reported a diverse range of outcomes in education, employment, relationships and reproduction. The most consistent variable associated with difficulty attaining adult milestones was hydrocephalus, the presence of which reduced the likelihood of living independently (p ≤ 0.001), having a partner (p = 0.003) and reproducing (p ≤ 0.001), but did not contribute to reduced life satisfaction.

CONCLUSIONS

Adults with MMC, especially those without hydrocephalus, can obtain gainful employment, live independently, form partner relationships and have children, and these achievements contribute to life satisfaction. While MMC does not affect overall reported life satisfaction for adults, attention should be paid to specific domains with less reported satisfaction.

Effectiveness of an upper extremity exercise device and text message reminders to exercise in adults with spina bifida: a pilot study

Obesity, deconditioning, cognitive impairment, and poor exercise tolerance are health issues concerning adults with spina bifida (SB). Our aim is to describe exercise participation and identify motivating tactics and exercise devices that increase participation. In a quasi-experimental randomized crossover design, the GameCycle was compared to a Saratoga Silver I arm ergometer. Personalized free or low-cost text/voice message reminders to exercise were sent. Nineteen young adults with SB were assigned to either the GameCycle or Saratoga exercise group. Within each group, participants were randomized to receive reminders to exercise, or no reminders, then crossed over to the opposite message group after eight weeks. Before and after a 16-week exercise program anthropometric, metabolic, exercise testing and questionnaire data, and recorded participation were collected. Miles traveled by the GameCycle group were significantly higher than the Saratoga exercise groups. No significant differences were found in participation between the message reminder groups. Low participation rates were seen overall. Those using the GameCycle traveled more miles. Barriers to exercise participation may have superseded ability to motivate adults with SB to exercise even with electronic reminders. Support from therapists to combat deconditioning and develop coping skills may be needed.

Virtual coach technology for supporting self-care

"Virtual Coach" refers to a coaching program or device aiming to guide users through tasks for the purpose of prompting positive behavior or assisting with learning new skills. This article reviews virtual coach interventions with the purpose of guiding rehabilitation professionals to comprehend more effectively the essential components of such interventions, the underlying technologies and their integration, and example applications. A design space of virtual coach interventions including self-monitoring, context awareness, interface modality, and coaching strategies were identified and discussed to address when, how, and what coaching messages to deliver in an automated and intelligent way. Example applications that address various health-related issues also are provided to illustrate how a virtual coach intervention is developed and evaluated. Finally, the article provides some insight into addressing key challenges and opportunities in designing and implementing virtual coach interventions. It is expected that more virtual coach interventions will be developed in the field of rehabilitation to support self-care and prevent secondary conditions in individuals with disabilities.

Functional impairment severity is associated with health status among older persons with intellectual disability and cerebral palsy

BACKGROUND

Studies have noted high rates of specific health disorders in adults with cerebral palsy (CP). However, it remains unclear how growing older with a lifelong neuromotor physical disability confers risk for health outcomes in adults who have both intellectual disability (ID) and CP.

AIM

To assess the relationship between health status in older adults with ID either with or without coincident diagnoses of CP.

METHOD

Health status data were drawn from 1373 adults aged 33 to 79 years with ID living in small group homes in New York State. Their health status was defined by the presence of common health disorders. Of these, 177 subjects had coincident CP. Prevalence data for nine diseases representing different organ systems were obtained and compared in individuals with and without CP. A Severity of Functional Impairment Index (SFII) was developed based on subjects' capabilities in activities of daily living (ADLs) and mobility. Two logistic regression analyses were conducted to determine if CP diagnosis was an independent predictor of health disorder prevalence, or rather exerted effects similar to those without CP via severity of functional impairment as determined by SFII scores. In addition, older age, gender, and severity of intellectual disability were examined as predictors of health disorder prevalence in all study subjects.

RESULTS

Individuals with CP had higher frequencies in four out of the nine health disorders (overweight/obesity, gastroesophageal reflux, urinary tract infections and dysphagia). Analysis revealed a statistically significant association between SFII score and CP diagnosis. CP diagnosis alone was a statistically significant predictor for all of the above four common disorders; however, after adjustment for SFII score was included in health disorder models, only dysphagia showed an independent correlation with a CP diagnosis.

CONCLUSION

With the exception of dysphagia, impairment in ADLs and walking capabilities, and not CP diagnosis alone, accounted for disparities in specific diseases. Although the diagnosis of CP may be correlated with functional impairment, it alone may play a minor role in determining health trajectories in older persons with conjoint ID and CP.

Health, mortality, and wellness issues in adults with cerebral palsy

For many years, children with cerebral palsy (CP) and their parents have been told that health and functional status stabilize by early adulthood. However, adults with CP report ongoing health conditions and aging and secondary conditions that are not always recognized or managed by their healthcare providers. There is a growing body of literature to better define the health, mortality, and wellness of those aging with CP. In general, adults with CP report good health, although health outcomes appear to be linked to the severity of CP and to increasing age. Studies reporting on lifespan warrant caution in interpretation because of biases in the survey and surveillance systems. It appears that lifespan of persons with CP is at or close to that of the typical population. The most commonly reported age-related changes and secondary conditions involve pain/fatigue, physical performance, and the musculoskeletal system. Not all adults have serious health problems, and many now recognize the aging process as a natural course of events. Few adults with CP engage in typical screening and health promotion activities due to a variety of barriers. There continues to be much to be learned and disseminated, in order to improve the care of adults with CP.

Everyday physical activity and community participation of adults with hemiplegic Cerebral Palsy

PURPOSE

To assess the level and potential determinants of everyday physical activity and participation in various life areas of adults with hemiplegic cerebral palsy (CP) in comparison with healthy subjects.

METHOD

In a cross-sectional study everyday physical activity was measured (Activity Monitor) in 16 adults with CP, aged 28 (3) years, and 16 age/gender matched healthy volunteers, aged 29 (3) years. Participation was assessed by means of validated questionnaires. Age, gender, body fat (skinfold thickness), muscle tone (Ashworth Scale), functional level and participation were assessed as potential determinants of everyday physical activity.

RESULTS

In adults with CP mean (SD) duration of dynamic activities during a day (10.6 [3.5]%) was comparable to healthy subjects (11.2 4%) (p = 0.66). In most life areas the level of participation was comparable for both groups, although adults with CP spent more time on non-intensive leisure activities. Participation in sports appeared to be a determinant of everyday physical activity in both groups.

CONCLUSIONS

The results indicate that the levels of everyday physical activity and community participation in adults with hemiplegic CP are comparable to levels in healthy comparison subjects.

Breast and cervical cancer screening practices among disabled women aged 40-75: does quality of the experience matter?

BACKGROUND

Women with disabilities (WWD) face significant barriers accessing healthcare, which may affect rates of routine preventive services. We examined the relationship between disability status and routine breast and cervical cancer screening among middle-aged and older unmarried women and the differences in reported quality of the screening experience.

METHODS

Data were from a 2003-2005 cross-sectional survey of 630 unmarried women in Rhode Island, 40-75 years of age, stratified by marital status (previously vs. never married) and partner gender (women who partner with men exclusively [WPM] vs. women who partner with women exclusively or with both women and men [WPW]).

RESULTS

WWD were more likely than those without a disability to be older, have a high school education or less, have household incomes <$30,000, be unemployed, and identify as nonwhite. In addition, WWD were less likely to report having the mammogram or Pap test procedure explained and more likely to report that the procedures were difficult to perform. After adjustment for important demographic characteristics, we found no differences in cancer screening behaviors by disability status. However, the quality of the cancer screening experience was consistently and significantly associated with likelihood of routine cancer screening.

CONCLUSIONS

Higher quality of cancer screening experience was significantly associated with likelihood of having routine breast and cervical cancer screening. Further studies should explore factors that affect quality of the screening experience, including facility characteristics and interactions with medical staff.

Prevalence of spina bifida among children and adolescents in metropolitan Atlanta

BACKGROUND

Although studies have examined the prevalence of spina bifida (SB) among births, little is known about the SB prevalence among children and adolescents. We estimated the prevalence of SB among children and adolescents in metropolitan Atlanta.

METHODS

This study used data from a population-based registry of birth defects, with information on children with SB (cases) born in five Atlanta counties from 1979-2002. The population at risk was derived from United States Census data and variations in SB prevalence were examined by race/ethnicity, sex, lesion level, age group under 20 years, 4-year birth cohort, and time period using Poisson regression.

RESULTS

From 1979 to 2002, SB birth prevalence decreased from 6.3 to 3.2 per 10,000 live births (p < 0.001) and SB prevalence within each age group also declined. In 2002, there were 211 children 0-19 years old surviving with SB in Atlanta (2.4 per 10,000 children 0-19 years old); prevalence of SB was higher among non-Hispanic whites and among children with lumbosacral lesion but did not vary by sex. With the exception of the most recent birth cohort (1998-2002), within each 4-year birth cohort, the prevalence of SB was generally higher among non-Hispanic whites than among non-Hispanic blacks.

CONCLUSIONS

This study provides minimum prevalence estimates among children and adolescents with SB in metropolitan Atlanta, and identifies race/ethnic disparities in such prevalence estimates. This information could be useful for assessing the specialized health care needs for children with SB and the possible reasons for the racial/ethnic variation in prevalence of SB.

A prospective gait analysis study in patients with diplegic cerebral palsy 20 years after selective dorsal rhizotomy

OBJECTIVES

Selective dorsal rhizotomy (SDR) has been widely performed for the reduction of spasticity in patients with cerebral palsy during the past 2 decades. The objective of this study was to determine whether the surgery has yielded long-term functional benefits for these patients.

METHODS

The authors present results from a prospective 20-year follow-up study of locomotor function in 13 patients who underwent an SDR in 1985. For comparison, we also present gait data for 48 age-matched healthy controls (12 at each of 4 time points). Patients were studied preoperatively and then at 1, 3, 10, and 20 years after surgery. Study participants were recorded in the sagittal plane while walking using a digital video camera, and 6 standard gait parameters were measured.

RESULTS

In this group of patients 20 years after surgery, knee range of motion (ROM) was on average 12 degrees greater than preoperative values (p < 0.001). Hip ROM before surgery was no different from that in the healthy control group. This parameter increased markedly immediately after surgery (p < 0.001) but had returned to normal after 20 years. The knee and hip midrange values-a measure of the degree of "collapse" due to muscle weakness after surgery-had returned to preoperative levels after 20 years, although they were respectively 11 and 8 degrees greater than those in healthy controls. Both temporal-distance parameters (dimensionless cadence and dimensionless step length) were significantly greater at 20 years than preoperative values (cadence, p = 0.003; step length, p = 0.02), leading to improved walking speed.

CONCLUSIONS

Twenty years after undergoing SDR, our patients showed improved locomotor function compared with their preoperative status.

Selective dorsal rhizotomy: long-term experience from Cape Town

INTRODUCTION

Given the large number of cerebral palsy patients who have undergone selective dorsal rhizotomy in the past two decades, it is clearly imperative that the clinical community be provided with objective and compelling evidence of the long-term sequelae of the procedure.

MATERIALS AND METHODS

In the early 1980s, Peacock in Cape Town shifted the site of the rhizotomy from the conus medullaris to the cauda equina, and in the past 25 years, more than 200 children have been operated on. We have studied the incidence of spinal deformities after multiple-level laminectomy and recorded a 20% incidence of isthmic spondylolysis or grade-I spondylolisthesis. We have also conducted a long-term prospective gait analysis study on a cohort of 14 ambulatory patients who were operated on in 1985.

RESULTS

Ten years after surgery, our patients had increased ranges of motion that were within normal limits. Step length was significantly improved, although cadence was unchanged postoperatively and was significantly less than normal age-matched control subjects.

DISCUSSION

We have recently tracked down all 14 patients from the original cohort and are currently completing a 20-year prospective follow-up analysis of their neuromuscular function and gait. Our preliminary data suggest that selective dorsal rhizotomy is not only an effective method for alleviating spasticity but it also leads to long-term functional benefits.

What Do We Really Know About the Transition to Adult-Centered Health Care? A Focus on Cerebral Palsy and Spina Bifida

OBJECTIVES

To address the lack of synthesis regarding the factors, processes, and outcomes specific to the transition from child-centered to adult-centered health care for people with cerebral palsy (CP) and spina bifida (SB); more specifically, to identify barriers, to outline key elements, to review empirical studies, and to make clinical and research recommendations.

DATA SOURCES

We searched Medline and CINAHL databases from 1990 to 2006 using the key words: transition, health care transition, pediatric health care, adult health care, health care access, health care use, chronic illness, special health care needs, and physical disability. The resulting studies were reviewed with a specific focus on clinical transition for persons with CP and SB, and were supplemented with key information from other diagnostic groups.

STUDY SELECTION

All studies meeting the inclusion criteria were included.

DATA EXTRACTION

Each article classified according to 5 criteria: methodology, diagnostic group, country of study, age group, and sample size.

DATA SYNTHESIS

We identified 149 articles: 54 discussion, 21 case series, 28 database or register, 25 qualitative, and 34 survey articles (some included multiple methods). We identified 5 key elements that support a positive transition to adult-centered health care: preparation, flexible timing, care coordination, transition clinic visits, and interested adult-centered health care providers. There was, however, limited empirical evidence to support the impact of these elements.

CONCLUSIONS

This review summarizes key factors that must be considered to support this critical clinical transition and sets the foundation for future research. It is time to apply prospective study designs to evaluate transition interventions and determine long-term health outcomes.

Communicating with nurses: the experiences of 10 adults with cerebral palsy and complex communication needs

The aim of this study was to explore the experiences of patients with cerebral palsy and complex communication needs (CCN) in hospital. Ten adults with cerebral palsy and CCN participated in semistructured interviews about their recent hospital experiences. Along with identifying barriers to successful communication, the participants suggested strategies to improve the hospital communication experience. The findings are discussed in relation to (1) preparing adults with cerebral palsy and CCN for communication in hospital communication and (2) training and supporting nurses in effectively communicating with these patients.

Youth and Young Adults With Cerebral Palsy: Their Use of Physician and Hospital Services

OBJECTIVES

To examine patterns of health care utilization among youth and young adults who have cerebral palsy (CP) and to provide information to guide the development of health services for adults who have CP.

DESIGN

This study analyzed health insurance data for outpatient physician visits and hospital admissions for a 4-year period.

SETTING

Six children's treatment centers in Ontario, Canada.

PARTICIPANTS

The sample included 587 youth and 477 adults with CP identified from health records. Youths were 13 to 17 years of age, and adults were 23 to 32 years of age at the end of the data range.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

We computed the annual rates of outpatient physician visits and hospitalizations per 1000 persons and compared these with rates for the general population.

RESULTS

Annual rates of outpatient physician visits were 6052 for youth and 6404 for adults with CP, 2.2 times and 1.9 times higher, respectively, than rates for age-matched peers (P<.01). Specialists provided 28.4% of youth visits but only 18.8% of adult visits. Annual hospital admission rates were 180 for youth and 98 for adults with CP, 4.3 times and 10.6 times higher, respectively, than rates for age-matched peers (P<.01).

CONCLUSIONS

It appears that youth and adults with CP continue to have complex care needs and rely heavily on the health care system. Comprehensive services are essential to support their health as they move into youth and adulthood. However, there appear to be gaps in the adult health care system, such as limited access to specialist physicians.