Chronic conditions and disabilities among seniors: an analysis of population-based health and activity limitation surveys

Physical Activity Attenuates Total and Cardiovascular Mortality Associated With Physical Disability: A National Cohort of Older Adults

Background

Regular physical activity (PA) has been shown to protect against disability onset but, once the disability is present, it is unclear if PA might attenuate its harmful health consequences. Thus, we examined if mortality risk associated with physical disability can be offset by PA among older adults.

Methods

We used data from a cohort of 3,752 individuals representative of the noninstitutionalized population aged 60 years and older in Spain. In 2000-2001, participants self-reported both PA levels (inactive, occasionally, monthly, weekly) and five physical disabilities (agility, mobility, global daily activities, instrumental activities of daily living, and self-care). Individuals were prospectively followed through 2014 to assess incident deaths.

Results

The mean follow-up was 10.8 years, with a total of 1,727 deaths, 638 of them due to cardiovascular disease (CVD). All disability types were associated with higher total and CVD mortality. Being physically active (ie, doing any PA) was associated with a statistically significant 26%-37% and 35%-50% lower risk of total and CVD death, respectively, across types of disability. As compared with those being physically active and without disability, those who were inactive and had a disability showed the highest mortality risk from total (hazard ratios from 1.52 to 1.90 across disabilities, all p < .05) and from CVD (hazard ratios from 1.99 to 2.24 across disabilities, all p < .05). Total and CVD mortality risk was similar in physically active participants with disabilities and in inactive individuals without disability.

Conclusions

In older adults, PA could attenuate the increased risk of mortality associated with physical disability.

Wheelchair accessibility to public buildings in the Kumasi metropolis, Ghana

BACKGROUND

Accessibility implies making public places accessible to every individual, irrespective of his or her disability or special need, ensuring the integration of the wheelchair user into the society and thereby granting them the capability of participating in activities of daily living and ensuring equality in daily life.

OBJECTIVE

This study was carried out to assess the accessibility of the physical infrastructures (public buildings) in the Kumasi metropolis to wheelchairs after the passage of the Ghanaian Disability Law (Act 716, 2006).

METHODS

Eighty-four public buildings housing education facilities, health facilities, ministries, departments and agencies, sports and recreation, religious groups and banks were assessed. The routes, entrances, height of steps, grade of ramps, sinks, entrance to washrooms, toilets, urinals, automated teller machines and tellers' counters were measured and computed.

RESULTS

Out of a total of 84 buildings assessed, only 34 (40.5%) of the buildings, 52.3% of the entrances and 87.4% of the routes of the buildings were accessible to wheelchair users. A total of 25% (13 out of 52) of the public buildings with more than one floor were fitted with elevators to connect the different levels of floors.

CONCLUSION

The results of this study show that public buildings in the Kumasi metropolis are not wheelchair accessible. An important observation made during this study was that there is an intention to improve accessibility when buildings are being constructed or renovated, but there are no laid down guidelines as how to make the buildings accessible for wheelchair users.

How does peer similarity influence adult children caregivers' perceptions of support from peers? A mixed-method study

Due to the growing elderly population, adult children care-givers (ACCs) are increasingly providing complex care for one or both elderly parents. Social support from similar peers can mitigate care-giving-related health declines. To date, ‘peer similarity’ amongst care-givers has been predominantly investigated in the context of peer-matching interventions. However, because peer similarity is especially influential in ‘naturally occurring’ support networks, care-givers' everyday peer support engagement warrants further attention. Our goal was to explore care-givers' everyday peer support engagement and the influence of peer similarity on support perceptions. We employed a mixed-method design using Web-based surveys and in-depth qualitative interviews. The quantitative data were analysed using a hierarchical multiple while qualitative data were thematically analysed. Seventy-one ACCs completed the online questionnaire and 15 participated in a telephone interview. Peer similarity was positively and significantly associated with perceived support (β = 0.469, p < 0.0005) and explained 18.5 per cent of the additional variance. ACCs' narratives suggested the most important aspect of similarity was ‘shared care-giving experience’ as it optimised the support received from peers, and also enhanced the quality of the relationship. In conclusion, both data-sets underscored that peer similarity importantly influences support perceptions. The importance of ‘shared care-giving experience’ suggests that a more comprehensive understanding of this concept is needed to optimise peer-matching endeavours. Peer similarity's influence on relationship quality should also be explored.

Multimorbidity, health and aging in Canada and Australia: a tale of two countries

BACKGROUND

Multimorbidity has been recognized as a major public health issue, negatively affecting health-related quality of life, including physical, functional, mental, emotional, and social domains, as well as increasing health care utilization. This exploratory study examines selected health outcomes associated with multimorbidity across older age groups/cohorts and gender, comparing Canada and Australia.

METHODS

Data were drawn from the 2008/09 Canadian Community Health Survey and the 2009 Australian HILDA survey. Seven major chronic conditions were identical across the two data sets, and were combined into an additive measure of multimorbidity. OLS and logistic regression models were performed within age group (45-54, 55-64, 65-74, 75+) and gender to estimate associations between multimorbidity and several health-related outcomes, including: loneliness, life satisfaction, perceived health, mobility restriction, and hospital stays, adjusting for marital status, education and foreign born status.

RESULTS

Overall, country-level differences were identified for perceptions of loneliness, life satisfaction, and perceived health. Australians tended to experience a greater risk of loneliness and lower self-rated health in the face of multimorbidity than Canadians, especially among older men. Canadians tended to experience lower life satisfaction associated with multimorbidity than Australians. No country-level differences were identified for associations between multimorbidity and hospital stays or mobility limitations.

CONCLUSIONS

The associations between multimorbidity and health are similar between the two countries but are variable depending on population, age group/cohort, and gender. The strongest country-level associations are for indicators of health-related quality of life, rather than health care or mobility limitation outcomes.

Modifiable Impairments Predict Progressive Disability Among Older Persons

Our purpose was to determine the extent to which a predetermined set of modifiable impairments predicted progression of disability. Method: We conducted a 3-year follow-up of two community-based cohorts of older adults. The impairment areas included lower extremity, upper extremity, hearing, vision, and affect. Home management and social or productive activities were the domains of function investigated. Results: All five impairments were of at least borderline significance in predicting decline in both functional domains in both cohorts with the exception of hearing for home management activities. The five impairments together explained from 17% to 23% of the decline seen in the functional outcomes (partial R2s 0.17 to 0.23). Discussion: Five prevalent and potentially modifiable impairments explained much of the progressive disability experienced. Given the priority that older patients place on function as a health outcome, these impairments should be routinely assessed and modified.

The experiences and needs of Chinese-Canadian stroke survivors and family caregivers as they re-integrate into the community

Stroke is a leading cause of adult disability and community re-integration is a priority for stroke rehabilitation. In North America, we have a growing population of individuals whose first language is not English. Little is known about the experiences of visible minorities living in North America as they re-integrate into the community post stroke or how these experiences change over time. Specifically, this research aimed to explore the experiences and needs of Chinese stroke survivors and family caregivers as they return to community living using the Timing it Right Framework as a conceptual guide. We recruited Cantonese-speaking stroke survivors and family caregivers from outpatient rehabilitation programmes. Using qualitative interviews conducted in Cantonese or English, we examined their experiences and needs as they return to community living and explored the influence of culture and time on their experiences. The interviews were transcribed and translated, and then analysed using framework analysis. Using framework analysis, we coded the data corresponding to the phases of the Timing it Right framework to determine the influence of time on the themes. We interviewed five Cantonese-speaking stroke survivors and 13 caregivers in 2009. We identified two main themes: (i) Participants' education and support needs change over time and (ii) Chinese resources are needed across care environments. These resources include access to care in their preferred language, traditional Chinese medicine, and Chinese food during their recovery and rehabilitation. To optimise Chinese stroke survivors' and caregivers' community re-integration, healthcare professionals should provide timely and accessible education and be aware of the role of Chinese diet and traditional medicine in stroke survivors' rehabilitation.

Factors that contribute to adult children caregivers' well-being: a scoping review

The ageing of the population will increasingly result in reliance on the family for care in the community. Existing reviews have provided insights into the needs and health outcomes of family caregivers, but are disproportionately skewed towards spousal caregivers. Presently, a large majority of family caregivers are adult children. Adult children are distinct from spousal caregivers in terms of the combination of roles they occupy and the relationship they have with the care recipient. These unique considerations can have important implications for their well-being. A growing body of literature has investigated the factors that contribute to adult children caregivers' (ACCs) well-being; however, no reviews to date have synthesised this body of literature or appraised its methodological quality. Our objective was to identify the range and types of factors that contribute to ACC well-being across studies. A scoping review was conducted. Medline, Psycinfo, EMBASE and CINAHL databases (January 1996-August, 2012) were systematically searched for studies investigating ACC well-being. Inclusion/exclusion criteria were applied, methodological quality was appraised, the data were charted and a narrative synthesis was conducted. Fifty-five studies met our inclusion criteria. Factors that contribute to ACC well-being were found to be either: (i) care recipient-related (e.g. nature of limitations, amount of care required); (ii) caregiver-related (e.g. psychological dispositions of the ACC); or (iii) socially embedded (e.g. parent-child relationship, multiple role involvement, social support available to the ACC). Socially embedded factors that contribute to ACC well-being have received the most attention in the literature. Among these factors, ACC well-being is uniquely impacted by the quality of the parent-child relationship and combination of roles occupied. The majority of studies were cross-sectional. Future studies should therefore employ a longitudinal design to inform our understanding of the changes that take place in the parent-child relationship and multiple role involvement across the care-giving trajectory.

Arthritis has an impact on the daily lives of Canadians young and old: results from a population-based survey

Background

There is a perception that the impacts of arthritis are greatest among older adults. However, the effect of age on health-related outcomes in individuals with arthritis has not been explicitly studied. This study examined whether the physical and mental health impacts of arthritis are greater in older (75+ years) versus younger (20–44, 45–64 and 65–74 years) Canadian adults.

Methods

Data were from the arthritis component of the 2009 Survey on Living with Chronic Diseases in Canada. The responses were weighted to be representative of Canadians (≥20 years) with arthritis. Associations between age and the prevalence of severe/frequent joint pain, severe/frequent fatigue, sleep limitations, instrumental activities of daily living (IADLs) limitations, high levels of stress, suboptimal general and suboptimal mental health, were examined descriptively prior to conducting multivariate log-binomial regression analyses.

Results

A total of 4565 respondents completed the survey (78 % response rate). Individuals with arthritis were mostly female (63 %), of working age (57 %) and overweight or obese (67 %). Upon adjusting for covariates, younger (20–44 years) and/or middle aged (45–64 years) adults were more likely than those older (75+ years) to report severe/frequent joint pain, sleep limitations, high levels of stress and suboptimal mental health. After adjusting for covariates, age was not associated with IADL limitations, severe/frequent fatigue or suboptimal general health.

Conclusions

Contrary to the belief that older adults with arthritis experience more severe physical and mental health outcomes, we found that older adults were less likely to report worse outcomes than younger adults. In light of these findings, public health messaging should stress that arthritis does not just affect the elderly and emphasize the importance of timely diagnosis and management at all ages in order to prevent or, minimize arthritis-related impairment.

The mobility gap between older men and women: the embodiment of gender

OBJECTIVES

To present the study design and baseline results of the longitudinal International Mobility in Aging Study (IMIAS) on gender differences in physical performance and mobility disability prevalence in five diverse societies.

METHODS

Data are from surveys on random samples of people aged 65-74 years at Canadian (Kingston, Ontario; Saint-Hyacinthe, Quebec), Mediterranean (Tirana, Albania) and Latin American sites (Natal, Brazil; Manizales, Colombia) (N=1995). Mobility disability was defined as reporting difficulty in walking 400m or climbing stairs. Activities of daily living (ADL) disability was based on any self-reported difficulty in five mobility-related ADLs. The short physical performance battery (SPPB) was used to assess physical performance. Poisson regression models were fitted to estimate prevalence ratios.

RESULTS

Age-adjusted prevalence of low SPPB, mobility disability and ADL disability were higher in women than in men in all sites except for Kingston. After adjustment for education and income, gender differences in SPPB and ADL disability attenuated or disappeared in Saint-Hyacinthe and Manizales but remained large in Tirana and Natal and mobility disability remained more frequent in women than in men at all sites except Kingston. After further adjustment by chronic conditions and depressive symptoms, gender differences in mobility remained large at all sites except Kingston but only in Tirana did women have significantly poorer physical performance than men.

DISCUSSION

Results provide evidence for gender as a risk factor to explain poorer physical function in women and suggest that moving toward gender equality could attenuate the gender gap in physical function in old age.

Estimating multiple morbidity disease burden among older persons: a convergent construct validity study to discriminate among six chronic illness measures, CCHS 2008/09

Background

Since approximately two in three older adults (65+) report having two or more chronic diseases, causes and consequences of multimorbidity among older persons has important personal and societal issues. Indeed, having more than one chronic condition might involve synergetic effects, which can increase impact on disabilities and quality of life of older adults. Moreover, persons with multimorbidity require more health care treatments, implying burden for the person, her/his family and the health care system.

Methods

Using the 2008/09 Canadian Community Health Survey (CCHS), this paper assesses the convergent construct validity of six measures of multimorbidity for persons aged 65 and over. These measures include: 1) Multimorbidity Dichotomized (0, 1+ conditions); 2) Multimorbidity Dichotomized (0/1, 2+); 3) Multimorbidity Additive Scale; 4) Multimorbidity Weighted by the Health Utility (HUI3) Scale; 5) Multimorbidity Weighted by the OARS Activity of Daily Living (ADL) Scale; and 6) Multimorbidity Weighted by HUI3 (using beta coefficients). Convergent construct validity was assessed using correlations and OLS regression coefficients for each of the multimorbidity measures with the following social-psychological and health outcome variables: life satisfaction, perceived health, number of health professional visits, and medication use.

Results

Overall, the two dichotomies (scales #1 & #2) showed the weakest construct validity with the health outcome variables. The additive chronic illness scale (#3) and the multimorbidity weighted by ADLs (#5), performed better than the other two weighted scales using (HUI #4 & #6). Measurement errors apparent in the dichotomous multimorbidity measures were amplified for older women, especially for life satisfaction and perceived health, but decreased when using the scales, suggesting stronger validity of scales #3 through #6.

Conclusions

To properly represent multimorbidity, using dichotomous measures should be used with caution. When only prevalence data are available for chronic conditions, such as in the CCHSs or CLSA, an additive multimorbidity scale can better measure total illness burden than simple dichotomous or other discrete measures.

Daughters providing poststroke care: perspectives on the parent-child relationship and well-being

Stroke is a leading cause of disability and dependence on the family, specifically daughter caregivers. The quality of the parent-child relationship can influence the experiences and well-being of daughters. Little is known about this in the context of stroke caregiving. We aimed to explore daughters' perceptions of changes in the relationship with their parent and how these changes contribute to their well-being. We used a qualitative descriptive design. Twenty-three daughters completed one in-depth interview that was transcribed, reviewed, coded, and categorized to generate themes. The parent-child relationship was central to each of the three themes: It (a) led daughters to take on the caregiving role, (b) changed as a result of caregiving, and (c) contributed to daughters' physical and emotional health. Targeted counseling that addresses changes in the parent-child relationship can help mitigate losses in communication and intimacy between daughters and parents. Insight into temporal relationship changes is needed.

Stroke family caregivers' support needs change across the care continuum: a qualitative study using the timing it right framework

PURPOSE

Family caregivers provide essential support as stroke survivors' return to community living, but it is not standard clinical practice to prepare or provide ongoing support for their care-giving role. In addition, health care professionals (HCPs) experiences with providing support to caregivers have not been explored previously. The objectives of this qualitative study were to: (1) explore the support needs over time from the perspective of caregivers, (2) explore the support needs over time from the perspective of HCPs, and (3) compare and contrast caregivers' and HCPs' perspectives.

METHODS

A qualitative study with stroke family caregivers (n = 24) and HCPs (n = 14). In-depth interviews were audio taped, transcribed, and analyzed using Framework Analysis.

RESULTS

Three main themes emerged concerning: (1) types and intensity of support needed; (2) who provides support and the method of providing support; and (3) primary focus of care. These themes are discussed in relation to the TIR framework.

CONCLUSIONS

Caregivers' needs for support and the individuals most suited to providing support change across the stroke survivor's recovery trajectory. Changes to service delivery to better support caregivers may include: (1) addressing caregivers' changing needs across the care continuum; (2) implementing a family-centered model of care; and (3) providing 7-day per week inpatient rehabilitation.

Age-related health hazards in old patients with first-time referral to a rheumatologist: a descriptive study

Objective. To study the prevalence of generic age-related health hazards in elderly patient referred to a rheumatologist. Methods. Patients aged 75 or older referred to a specialized gerontorheumatological outpatient service over a period of 2 years were studied prospectively to determine the prevalence of comorbidities, a history of falls, inactivity, cognitive dysfunction, loneliness, and depression in this patient group. Results. A group of 154 patients were included in the study. Comorbidities were observed in 88% of the patients. At least one fall was reported in the last year by 44% of the patients; 44% of the patients reported low levels of health-enhancing physical activity. Depressed mood and loneliness were elevated in 30% and 31% of the patients, respectively. Mild or moderate cognitive impairment was observed in 13% of the patients. Conclusion. Patients in this study were characterized by poor physical ability, high levels of pain, and high prevalence of age-related health hazards.

Morbidity in aged Finns: a systematic review

AIM

The aim was to carry out a systematic review of original studies about morbidity in the aged in Finland.

METHODS

Publications with data on morbidity in the aged (≥65 years) in peer-reviewed scientific journals in Finnish and English were systematically searched for in literature databases, websites of National Institute of Health and Welfare (NIHW), National Public Health Institute (NPHI), and Stakes and reference lists of retrieved articles. Publications from 1990 onwards were included.

RESULTS

The search produced 39 publications about morbidity in the aged in Finland fulfilling the inclusion criteria. The most common disease categories in the aged were cardiovascular diseases (CVDs), musculoskeletal disorders (MSDs), hypertension, orthostatic hypotension (OH), insomnia, diabetes, articular diseases, diseases causing cognitive decline, and depression. The prevalence of many of these diseases increased with age.

CONCLUSIONS

The morbidity increases with aging, and even the oldest-old are not exceptionally healthy. Because of the increasing number of aged people, the absolute use of health and social services by this population sector will most probably increase in Finland and other developed countries.

Prevalence, Risk Factors and Self-Reported Medical Causes of Seeing and Hearing-Related Disabilities Among Older Adults

On a examiné la prévalence, les facteurs de risque et les troubles médicaux associés aux déficiences de la vue et de l'ouïe chez les adultes canadiens de 55 ans et plus. On a établi un échantillonnage aléatoire à partir des recensements canadiens de 1986 et 1991 et on a demandé aux citoyens qui en faisaient partie de remplir le Sondage sur la santé et les limitations d'activité (ESLA) de 1986 et 1991. On a constaté que les aîné(e)s de 65 ans et plus présentaient plus de déficiences sensorielles que ceux de 55 à 64 ans. Les hommes signalaient plus de difficultés de l'ouîe que les femmes tandis que les femmes présentaient plus de difficultés de la vue que les hommes. On a constaté que l'incidence des difficultés sensorielles semblait augmenter avec l'âge et avec la diminution de revenu total de la maisonnée. Ce sont les cataractes et la surdité qui ont été le plus souvent mentionnées comme cause de restriction des activités de la vie quotidienne dans les deux groupes d'âge. Les difficultés sensorielles sont fréquentes chez les aîné(e)s. Les initiatives de santé publique devraient se pencher sur les difficultés de la vue et de l'ouïe, particulièrement chez les aîné(e)s, les femmes et les gens à faible revenu.

Population attributable risk for functional disability associated with chronic conditions in Canadian older adults

OBJECTIVES

to investigate the population impact on functional disability of chronic conditions individually and in combination.

METHODS

data from 9,008 community-dwelling individuals aged 65 and older from the Canadian Study of Health and Aging (CSHA) were used to estimate the population attributable risk (PAR) for chronic conditions after adjusting for confounding variables. Functional disability was measured using activity of daily living (ADL) and instrumental activity of daily living (IADL).

RESULTS

five chronic conditions (foot problems, arthritis, cognitive impairment, heart problems and vision) made the largest contribution to ADL- and IADL-related functional disabilities. There was variation in magnitude and ranking of population attributable risk (PAR) by age, sex and definition of disability. All chronic conditions taken simultaneously accounted for about 66% of the ADL-related disability and almost 50% of the IADL-related disability.

CONCLUSIONS

in community-dwelling older adults, foot problems, arthritis, cognitive impairment, heart problems and vision were the major determinants of disability. Attempts to reduce disability burden in older Canadians should target these chronic conditions; however, preventive interventions will be most efficient if they recognize the differences in the drivers of PAR by sex, age group and type of functional disability being targeted.

Ageing, the urban-rural gap and disability trends: 19 years of experience in China - 1987 to 2006

BACKGROUND

As the age of a population increases, so too does the rate of disability. In addition, disability is likely to be more common in rural compared with urban areas. The present study aimed to examine the influence of rapid population changes in terms of age and rural/urban residence on the prevalence of disability.

METHODS

Data from the 1987 and 2006 China Sampling Surveys on Disability were used to estimate the impacts of rapid ageing and the widening urban-rural gap on the prevalence of disability. Stratum specific rates of disability were estimated by 5-year age-group and type of residence. The decomposition of rates method was used to calculate the rate difference for each stratum between the two surveys.

RESULTS

The crude disability rate increased from 4.89% in 1987 to 6.39% in 2006, a 1.5% increase over the 19 year period. However, after the compositional effects from the overall rates of changing age-structure in 1987 and 2006 were eliminated by standardization, the disability rate in 1987 was 6.13%, which is higher than that in 2006 (5.91%). While in 1987 the excess due to rural residence compared with urban was <1.0%, this difference increased to >1.5% by 2006, suggesting a widening disparity by type of residence. When rates were decomposed, the bulk of the disability could be attributed to ageing, and very little to rural residence. However, a wider gap in prevalence between rural and urban areas could be observed in some age groups by 2006.

CONCLUSION

The increasing number of elderly disabled persons in China and the widening discrepancy of disability prevalence between urban and rural areas may indicate that the most important priorities for disability prevention in China are to reinforce health promotion in older adults and improve health services in rural communities.

Appreciating the Predicament of Housebound Older Adults with Arthritis: Portrait of a Population

This paper draws a socio-demographic, physical, psychosocial, and behavioural profile of housebound older adults with arthritis and compares older adults with rheumatoid arthritis to those with osteoarthritis. Data from 125 housebound older adults with osteoarthritis (65%) or rheumatoid arthritis (35%) were compared to published samples and to population data using appropriate weighting. Respondents were mainly women, living alone, mean age 77 years (SD = 10.50). Symptoms of stiffness, fatigue, and pain intensity were moderate to severe, and a substantial proportion (51.4%) reported depression. Participants reported low levels of health behaviours such as exercise. Overall, older adults with rheumatoid arthritis were significantly younger, reported less pain and limitations, were more optimistic and satisfied with their social life, and had a higher self-efficacy than older adults with osteoarthritis. Home-based pain self-management programs should be constructed considering the unique profiles and needs of this population.

Comparative, validity and responsiveness of the HOOS-PS and KOOS-PS to the WOMAC physical function subscale in total joint replacement for osteoarthritis

OBJECTIVE

To evaluate the internal consistency of the Hip disability and Osteoarthritis Outcome Score-Physical Function Short-form (HOOS-PS) and the Knee injury and Osteoarthritis Outcome Score-Physical Function Short-form (KOOS-PS) in total hip replacement (THR) and total knee (TKR) replacement. Construct validity and responsiveness were compared to the Western Ontario McMaster Universities' Osteoarthritis Index (WOMAC) Likert 3.0 physical function (PF) subscale and the PF excluding the items in the short measures (PF-exclusions).

METHODS

Participants completed the full HOOS or KOOS, measures of fatigue, anxiety, depression and the Chronic Pain Grade (CPG) pre-surgery and the HOOS or KOOS 6 months post-surgery. Internal consistency for the HOOS-PS and KOOS-PS was calculated using Cronbach's alpha. For construct validity, it was hypothesized that correlations between the HOOS-PS or KOOS-PS and PF and PF-exclusions with fatigue, CPG, anxiety and depression and HOOS/KOOS pain scales would differ by magnitudes of <0.1. Standardized response means (SRMs) were calculated for the HOOS-PS, KOOS-PS, PF and PF-exclusions and hypothesized to be >1.

RESULTS

The THR group (n=201) had a mean age of 62.3 years; 53.2% were female. The TKR group (n=248) had a mean age of 64.5 years; 63.7% were female. Cronbach's alpha was 0.79 and 0.89 for the HOOS-PS and KOOS-PS, respectively, confirming that the measures represented a homogeneous construct. The correlation of the HOOS-PS to the PF and PF-exclusions was 0.90 and 0.86, respectively; r=0.90 (PF) and r=0.85 (PF-exclusions) for the KOOS-PS. The results supported the construct validity hypotheses. For THR, the SRM was 1.5, 1.7 and 1.7 for the HOOS-PS, PF and PF-exclusions; for TKR, the SRM was 1.4, 1.5 and 1.7, respectively.

CONCLUSIONS

The short HOOS-PS and KOOS-PS represent homogenous short measures of PF with similar construct validity and responsiveness to the 17-item PF. The HOOS-PS and KOOS-PS are parsimonious, valid and responsive for evaluating PF in THR and TKR.

Graphical models illustrated complex associations between variables describing human functioning

OBJECTIVE

To examine whether graphical modeling is a potentially useful method for the study of human functioning using data collected by means of the International Classification of Functioning, Disability and Health (ICF).

STUDY DESIGN AND SETTING

The applicability of the method was examined in a convenience sample of 616 patients from a cross-sectional multicentric study undergoing early postacute rehabilitation. Functioning was qualified using 115 second-level ICF categories. The modeling was carried out on a data set with imputed missing values. The least absolute shrinkage and selection operator (LASSO) for generalized linear models was used to identify conditional dependencies between the ICF categories. Bootstrap aggregating was used to enhance the accuracy and validity of model selection.

RESULTS

The resulting graph showed highly meaningful relationships. For example, one structure centered around speaking and included three paths addressing conversation, speech functions, and mental functions of language.

CONCLUSION

Graphical modeling of human functioning using data collected by means of the ICF yields clinically meaningful results. The structures found may be the basis for the identification of suitable targets for rehabilitation interventions, the identification of confounders and intermediate variables, and the selection of parsimonious sets of variables for multivariate epidemiological modeling.

The development of a short measure of physical function for hip OA HOOS-Physical Function Shortform (HOOS-PS): an OARSI/OMERACT initiative

OBJECTIVE

To derive a cross-culturally valid, short measure of physical function using function subscales (daily living and sports and recreation) of the Hip disability and Osteoarthritis Outcome Score (HOOS).

METHODS

Rasch analysis was conducted on data from individuals from multiple countries who had hip osteoarthritis (OA). Fit of the data to the Rasch model was evaluated by model chi(2) and item fit statistics (chi(2), size of residual, and F-test). Differential item functioning was evaluated by gender, age and country. Unidimensionality was evaluated by factor analysis of residuals. Individual data sets were analyzed and data pooled and re-analyzed for fit to the model. Regression modeling was conducted to derive a nomogram converting raw summed scores to Rasch derived interval scores.

RESULTS

Seven data sets were included (n=2991), ages 19-96 years, male/female ratio was 1:1.23. The final model included five HOOS items. From the easiest to most difficult, the items (logit) were as follows: sitting (1.832), descending stairs (0.729), getting in/out of bath or shower (0.255), twisting/pivoting on loaded leg (-0.221) and running (-2.595). The separation index was 0.80.

CONCLUSION

The daily activity and sports and recreational items of the HOOS were reduced to five items achieving a feasible, short measure of physical function with interval level properties. This tool has potential for use as the function component of an OA severity scoring system. Further testing of this measure is warranted.

"Timing It Right": a conceptual framework for addressing the support needs of family caregivers to stroke survivors from the hospital to the home

OBJECTIVE

Discuss family caregivers of stroke survivors' changing needs for education and support across the care continuum.

METHODS

Conceptual review.

RESULTS

Stroke is a serious, sudden onset illness requiring care across the care continuum. The focus of care, the individuals primarily responsible for providing that care, and patients' self-care abilities change across care environments. Often family members who provide support also experience changes in their caregiving role. To date, however, interventions for family caregivers have not explicitly considered their changing support needs. Our "Timing It Right" framework highlights family caregivers changing experiences and corresponding support needs across the care continuum. Five different phases of caregiver support are discussed: (1) event/diagnosis; (2) stabilization; (3) preparation; (4) implementation; (5) adaptation. The first two phases occur during acute care, the third occurs during acute care and/or in-patient rehabilitation, and the final two phases occur in the community.

CONCLUSIONS

Application of this framework has the potential to benefit future intervention efforts by identifying gaps in caregiver education, training, and support.

PRACTICE IMPLICATIONS

Recognition of family caregivers changing support needs across the care continuum will assist health care professionals to provide more timely and appropriate support.

Factors associated with restricted mobility outside the home in community-dwelling adults ages fifty years and older with knee pain: an example of use of the International Classification of Functioning to investigate participation restriction

OBJECTIVE

To investigate the links between knee pain characteristics and restricted mobility outside the home, and how these are influenced by mobility-specific activity limitation, age, sex, socioeconomic status, environmental factors, and comorbidity.

METHODS

We conducted a cross-sectional survey of community-dwelling adults age > or = 50 years. A total of 2,252 responders reporting pain in and around the knee in the last year were eligible. The primary outcome was self-reported restricted mobility outside the home in the previous 4 weeks (dichotomized as present or absent).

RESULTS

Knee pain severity was strongly associated with restricted mobility outside the home, an association largely mediated by perceived limitation in walking. After adjusting for demographic and socioeconomic characteristics, individual contributions from selected comorbidities, knee pain severity, limitation in walking, and specific environmental factors remained. These environmental factors included perceived need of aids and assistance (adjusted odds ratio [OR] 3.1, 95% confidence interval [95% CI] 2.2-4.4), poor access to public transportation (adjusted OR 2.3, 95% CI 1.4-3.9), and having no access to a car (adjusted OR 1.6, 95% CI 1.1-2.4).

CONCLUSION

There are a range of potential health and social targets that, if addressed, might reduce restricted mobility outside the home in middle-aged and older individuals with knee pain. Our results suggest that, in addition to treating the knee symptoms, such targets might include comorbidity, walking ability, and environmental barriers such as poor access to public transportation. Moreover, removing environmental barriers may reduce immobility outside the home even in the continued presence of osteoarthritis symptoms and specific activity limitations.

Development and implementation of the Ontario Stroke System: the use of evidence

INTRODUCTION

The Ontario Stroke System was developed to enhance the quality and continuity of stroke care provided across the care continuum.

RESEARCH OBJECTIVE

To identify the role evidence played in the development and implementation of the Ontario Stroke System.

METHODS

This study employed a qualitative case study design. In-depth interviews were conducted with six members of the Ontario Stroke System provincial steering committee. Nine focus groups were conducted with: Regional Program Managers, Regional Education Coordinators, and seven acute care teams. To supplement these findings interviews were conducted with eight individuals knowledgeable about national and international models of integrated service delivery.

RESULTS

Our analyses identified six themes. The first four themes highlight the use of evidence to support the process of system development and implementation including: 1) informing system development; 2) mobilizing governmental support; 3) getting the system up and running; and 4) integrating services across the continuum of care. The final two themes describe the foundation required to support this process: 1) human capacity and 2) mechanisms to share evidence.

CONCLUSION

This study provides guidance to support the development and implementation of evidence-based models of integrated service delivery.

Waist circumference as a predictor of disability among older adults

OBJECTIVE

Few studies have addressed the association between abdominal obesity, as measured by waist circumference (WC), and disability in the elderly. Moreover, those studies were cross-sectional and yielded inconsistent results. The objective of this study was to examine longitudinally the association between WC and self-reported disability among older adults.

RESEARCH METHODS AND PROCEDURES

A prospective cohort study was conducted from 2001 to 2003 in 3235 persons (1411 men and 1824 women) representative of the non-institutionalized Spanish population ages 60 years and older. Baseline information was collected by home-based personal interviews and measurement of WC, weight, and height. Two years later, information on disability was obtained by telephone interview. The association of interest was summarized with odds ratios obtained by logistic regression.

RESULTS

Among persons reporting no disability at baseline, WC predicted disability 2 years later. After adjustment for age, education, tobacco use, alcohol consumption, and physical activity, men in the highest WC quintile had 2.17 (95% confidence interval, 1.15 to 4.09) times more risk of mobility disability and 4.77 (95% confidence interval, 2.50 to 9.13) times more risk of agility disability than those in the lowest quintile. Additional adjustment for BMI, chronic diseases, and cognitive function led to only a slight reduction in this association. Results were similar for women. No statistically significant association was observed between WC and restriction of daily activities, limitation in instrumental activities of daily living, and limitation in bathing or dressing, in either men or women.

DISCUSSION

WC predicts mobility and agility disability in old age. Avoidance of the highest values of WC might decrease the risk of disability in older adults.

Behavior change following a self-management intervention for housebound older adults with arthritis: an experimental study

BACKGROUND

This study examined the impact of a home-based self-management intervention for housebound older adults with arthritis on the adoption of health behaviors. The moderating role of socio-demographic, psychological, and physical characteristics in the process of behavior change was also investigated.

METHODS

Participants were 113 older adult women (n = 102) and men (n = 11) with osteoarthritis (OA) or rheumatoid arthritis (RA) who were randomly assigned to experimental (n = 68) or wait list control (n = 45) groups. Participants were interviewed using standardized questionnaires at baseline, pre-intervention, and post-intervention.

RESULTS

Adjusted multilevel modeling analyses indicated that from pre to post intervention, experimental participants significantly increased their weekly frequency of exercise and relaxation activities. Socioeconomic status and depression played a moderating role in this change for exercise with larger effects occurring among more privileged, non-depressed participants.

CONCLUSION

We conclude that a self-management intervention can successfully improve involvement in exercise and relaxation among housebound older adults with arthritis.

Accessibility of health clubs for people with mobility disabilities and visual impairments

OBJECTIVE

We sought to examine the accessibility of health clubs to persons with mobility disabilities and visual impairments.

METHODS

We assessed 35 health clubs and fitness facilities as part of a national field trial of a new instrument, Accessibility Instruments Measuring Fitness and Recreation Environments (AIMFREE), designed to assess accessibility of fitness facilities in the following domains: (1) built environment, (2) equipment, (3) swimming pools, (4) information, (5) facility policies, and (6) professional behavior.

RESULTS

All facilities had a low to moderate level of accessibility. Some of the deficiencies concerned specific Americans with Disabilities Act guidelines pertaining to the built environment, whereas other deficiency areas were related to aspects of the facilities' equipment, information, policies, and professional staff.

CONCLUSIONS

Persons with mobility disabilities and visual impairments have difficulty accessing various areas of fitness facilities and health clubs. AIMFREE is an important tool for increasing awareness of these accessibility barriers for people with disabilities.

Capability for daily activities in old people with rheumatoid arthritis: a population based study

OBJECTIVE

To describe the functional capacity for daily activities in old people with clinical rheumatoid arthritis (including juvenile rheumatoid arthritis (JRA)) in a population based cohort.

METHODS

A cohort of 700 people was randomly collected from the population older than 75 years in a Finnish town. Altogether 601 persons (86%) participated. Data were collected from clinical records and by interview, clinical examination, and questionnaire. Ability to carry out activities of daily living (ADL) was assessed by the Barthel index, and the IADL (instrumental activities of daily living) by the Lawton and Brody questionnaire.

RESULTS

16 people had clinical rheumatoid arthritis (one with JRA). The prevalence was 16/601 (2.7% (95% confidence interval, 1.7% to 4.5%)). Eight patients with rheumatoid arthritis (50%) obtained the best possible ADL figures, while three (19%) had very poor results. Seven (44%) could not dress themselves without help. Three (19%) were unable to walk, and five (31%) could not climb stairs. Sex and age adjusted results showed no statistical difference (ADL and IADL) between patients with clinical rheumatoid arthritis and rest of the cohort. Four patients (25%) had dementia, which was associated with the poor functional capacity.

CONCLUSIONS

The prevalence of the disease was unexceptional. The ability of old people with rheumatoid arthritis to carry out activities of daily living did not differ from the general population, but the disease may lead to severe disability on an individual level, especially when associated with dementia. It therefore remains a considerable challenge to the health care and social systems.

Prevalence of disability and associated social and health-related factors among the elderly in Spain: a population-based study

OBJECTIVES

To estimate the prevalence of disability and its association with morbidity and other social and health-related factors among Spain's non-institutionalized elderly population.

METHODS

Cross-sectional survey, by home-based personal interview, covering a sample of 4000 subjects representative of the non-institutionalized Spanish population aged 60 years and over. The relationship between disability and social and health-related study variables was studied using logistic regression.

RESULTS

A total of 72.9% of subjects reported some type of disability: 59.1% in agility, 51.6% in mobility, 40.1% in instrumental activities and 19.1% in activities of daily living. After adjusting for all relevant variables, disability showed to be significantly more frequent for: female gender (OR = 1.83; 1.53-2.19); more advanced age (OR = 4.54; 3.27-6.32); low/no educational level (OR = 2.01; 1.67-2.42); deteriorated cognitive status (OR = 1.67; 1.24-2.23); at least two chronic diseases (OR = 2.54; 2.01-3.20); poor perceived health status (OR = 3.02; 2.48-3.69); little physical activity (OR = 2.57; 1.94-3.42); and greater use of hospital care (OR = 1.34; 1.10-1.64).

CONCLUSIONS

Prevalence of disability among Spain's non-institutionalized elderly population is very high. This might be explained by a greater number of chronic diseases, a higher percentage of subjects with low educational level and a higher proportion of community-dwelling elderly persons than in Anglo-Saxon countries.

Arthritis onset and worsening self-rated health: A longitudinal evaluation of the role of pain and activity limitations

OBJECTIVE

To longitudinally explore the hypothesized role of worsening pain and development of activity limitations as mediators in the relationship between arthritis onset and worsening self-rated health (SRH).

METHODS

Data was obtained from the 1998/1999 and 2000/2001 cycles of the population-based Canadian longitudinal National Population Health Survey (n = 10,859; ages > or = 18; response rate: time 1 = 81.6%, time 2 = 89.2%). Respondents were asked about chronic conditions, pain, activity limitations, and self-perceived health; change over time was assessed. Change in effect of arthritis onset on worsening SRH upon considering potential mediators was assessed through multivariate logistic regression, controlling for sociodemographic characteristics and onset of other conditions.

RESULTS

Worsening pain fully explained the effect of arthritis onset on worsening SRH; a portion of the effect of worsening pain was mediated by the development of activity limitation. Residual direct effect of arthritis onset was statistically insignificant. Worsening pain and development of activity limitations also mediated a portion of the effects of onset of other chronic conditions but to a lesser extent than arthritis onset.

CONCLUSION

This is the first study to examine these relationships longitudinally. Identifying the role of mediators is necessary if target areas of prevention and/or management are sought, either at the individual or population level. Our results indicate that the development of arthritis has a significant impact on worsening SRH. Pain and development of activity limitations fully account for the relationship between arthritis onset and worsening SRH. High priority should be placed on prevention and management strategies for pain among people with arthritis.

Perceived need for workplace accommodation and labor-force participation in Canadian adults with activity limitations

We examined how perceived need for workplace accommodation affects labor-force participation in people with disabilities. We analyzed a Canadian survey with structural equation modeling to test a model incorporating activity limitations and perceived need for workplace accommodations. The results suggested that the effect of upper- and lower-body activity limitation on labor-force participation was mediated by perceived need for workplace accommodations. Thus, the provision of adequate workplace accommodations could enhance labor-force participation in people with disabilities.

The relationship between sensory impairment and functional independence among elderly

Background

It has been well established that increasing age is associated with decreasing functional ability in older adults. It is important to understand the specific factors that affect instrumental activities of daily living (IADL) and functional independence among older adults with sensory disabilities.

Methods

Nationally representative sample of adults aged 55 years and older with seeing or hearing disabilities were categorised into three sensory classifications: "Seeing Disabled but Hearing Abled" (SD-HA), "Hearing Disabled but Seeing Abled" (HD-SA), and both "Seeing and Hearing Disabled" (SD-HD). The additional category of "Seeing Disabled and/or Hearing Disabled" (SD and/or HD) was created to calculate the total of all individuals from the above categories who either had a seeing or hearing disability or both sensory disabilities. Respondents were asked to indicate whether they received assistance in performing seven IADL and their level of functional independence.

Results

The most common factors that affect IADL were heavy chores, grocery shopping and housework. Individuals with both seeing and hearing disabilities (SD-HD) reported having the most IADL restrictions, followed by individuals with only seeing disabilities (SD-HA) and only hearing disabilities (HD-SA). Individuals with severe sensory disabilities were generally more likely to report IADL restrictions and less likely to have decision-making control and be happy with their lives. In each sensory classification, females aged 55–64 years and 65 years and older reported more IADL restrictions than males.

Conclusion

Both seeing and hearing disabilities have a significant impact on restricting an individual's IADL.

Impact of cardiovascular diseases on activity limitations and need for help among older persons

BACKGROUND AND OBJECTIVE

The aim of this study was to estimate the importance of specific chronic cardiovascular diseases (CVDs) as determinants of disability.

METHODS

One thousand two hundred eighty-eight (86%) participants from a random population sample of 1,500 individuals (from two geographical regions of Finland) aged 65-74 years were interviewed and clinically examined in 1997.

RESULTS

CVDs were strongly associated with disability. However, mental disorders were the strongest determinant of disability. Of specific CVDs, cerebrovascular diseases in men, and myocardial infarction, heart failure, and cerebrovascular diseases in women were significantly associated with disability after adjustment for age and comorbidity. In men 33% and in women 24% of disability was attributable to CVD, excluding lone hypertension.

CONCLUSION

CVDs are important determinants of disability among Finns aged 65-74 years. Due to the growing number of elderly people with CVDs, disability associated with these diseases is likely to become a growing social and health burden to the community.

Prevention of cancer in the older person

Both primary and secondary cancer prevention may improve cancer control among older persons. Although chemoprevention of cancer is feasible, the agents currently used for chemoprevention have several complications. As a result, the use of these substances should be individualized based on risk-benefit ratio. It is reasonable to implement screening for cancer of the breast and of the large bowel in persons with a life expectancy of 5 years and longer. No definite recommendation may be issued at present related to screening for prostate, lung, and cervical cancer. Ongoing clinical trials may answer some of these questions.

A health-related fitness and functional performance test battery for middle-aged and older adults: feasibility and health-related content validity

OBJECTIVE

To evaluate the feasibility and health-related content validity of 6 health-related fitness (HRF) and 3 functional performance (FP) tests among middle-aged and older persons.

DESIGN

Cross-sectional methodologic study.

SETTING

Field laboratories in 3 communities of northeast Finland.

PARTICIPANTS

A regionally representative, community-based cohort of 55- to 79-year-old men (n=501) and women (n=632).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Health-related test exclusion rates (%) by age groups and odds ratios (ORs) of subjective health outcomes by fitness categories (least 20%, next 40%, most fit 40%).

RESULTS

The health-related test exclusion rates increased with age, mainly because of musculoskeletal health limitations among the women and cardiovascular and musculoskeletal health limitations among the men. With the exception of dynamic back extension, 1-leg squat, 1-leg standing balance, and the 1-km walk among the women 75 years and older, 85% or more of the subjects qualified for the HRF tests and 95% or more for the FP tests. Strong and graded associations were found for cardiorespiratory and musculoskeletal fitness and the FP test levels with perceived health and functional ability status among both the men and the women (OR range, 2-31). The motor fitness test level was primarily associated with functional ability status.

CONCLUSIONS

All the HRF and FP tests showed health-related content validity, and 4 of 6 of the HRF tests and all of the FP tests proved to be safe, with minor health-related test exclusions for middle-aged and older adults. The findings may help to target physical activity intervention toward persons at high risk for declining health and functional ability.

Longitudinal evaluation of economic and physical impact of Parkinson's disease

The cost of parkinsonism and Parkinson's disease (PD) is largely unknown although clinical experience suggests that the impact of this disease is substantial. Longitudinal data is presented for health status, disease symptoms, functional status, and financial costs for 70 participants with PD or parkinsonism. The sample was dichotomized into those rating their health as excellent, good, or very good ('good health') and those rating their health as fair or poor ('poor health'). The 'poor health' group were significantly more disabled at baseline. Symptoms increased between year 1 and 3 with greatest increases in fatigue, pain, and depression for the 'good health' group. At year 1, total direct cost/capita was about dollars 5000/year for both groups; indirect costs were dollars 5000 for the 'good health' group and dollars 15,000/year for the 'poor health' group. By year 3, total expenditures increased over 25% for the 'good health' group and nearly doubled for the 'poor health' group, while percent costs that were compensated declined for groups. Out of pocket, expenses were as high as dollars 3000/year for the 'poor health' group by year 3. Through analysis of the broad impact of PD, including non-neurological symptoms and economic ramifications, it is possible to better appreciate the impact of this chronic condition on overall quality of life.

The disproportionate impact of chronic arthralgia and arthritis among women

The heterogeneous group of diseases that causes chronic arthralgia and arthritis is the most common cause of activity limitation and disability among middle age and older women. For reasons that remain poorly understood this group of diseases affects women substantially more frequently than men. In particular, the prevalence rates of the most common causes of arthralgia and arthritis, osteoarthritis and rheumatoid arthritis, and the prevalence rates of less common diseases that cause arthralgia, including systemic lupus erythematosus, systemic sclerosis, and fibromyalgia, are between two and 10 times higher in women. Prevalence rates for most of these conditions increase with age, and may vary among populations. For example, in the United States, systemic lupus erythematosus is approximately three times as common among African-American women as among white women. All of these disorders typically have an insidious onset and variable course that can make diagnosis difficult. Yet, most patients with these diseases benefit from early diagnosis and early nonoperative treatments including patient education, patient participation in disease treatment, activity modification, assistive devices, and medications. Furthermore, early aggressive medical therapy may prevent development of permanent joint and visceral damage in patients with inflammatory diseases including rheumatoid arthritis, systemic lupus erythematosus, and systemic sclerosis. Failure to make the diagnosis of an underlying disease in patients with arthralgia may lead to inappropriate treatment or delay in treatment that can result in irreversible impairment. Because many women with these conditions seek medical care from orthopaedists, orthopaedic residency education and continuing medical education should place emphasis on early diagnosis and nonoperative treatment of patients with arthralgia and arthritis, and, when appropriate, early referral to rheumatologists.