Disability in older adults. 1: Prevalence, causes, and consequences

Gender Differences in Predictors of Physical Functioning Limitations Among the Elderly Population in Serbia: A Population-Based Modeling Study

Background and Objective: Active aging is influenced by various factors, including chronic diseases, multimorbidity, functional limitations, and disabilities. The presence of these factors might lead to greater dependence on caregivers and could present potential barriers to community engagement. Physical functioning might be considered as one of the vital components for healthier aging experience promotion and support in elderly people. This study aimed to assess self-perceived general health and related health characteristics among the elderly population in Serbia, with a focus on varying degrees of functional limitations, as well as to analyze the predictors of physical functioning limitations in relation to gender. Materials and Methods: This population-based modeling study included a representative sample of 3540 elderly individuals aged above 65 years from Serbia. We employed a dual approach to model the four distinct difficulty levels related to the two groups of limitations of physical functioning (PF1 and PF2) for both genders. The PF1 focused on walking half a kilometer on level ground without the assistance of any mobility aids, and the PF2 navigated a set of 12 steps of ascent and descent: Model 1: inability to execute PF1, Model 2: some/a lot of difficulty in PF1, Model 3: inability to execute PF2, and Model 4: some/a lot of difficulty in PF2. Further variables were evaluated: self-perceived general health, long-lasting health problems, and chronic diseases/chronic conditions. Logistic regression analysis was performed to assess predictors of physical functioning. The models' performance was presented. Results: Significant predictors were as follows: self-perceived general health (Model 1 (male OR: 8.639; female OR: 3.569); Model 2 (male OR: 2.759; female OR: 2.277); Model 3 (male OR: 24.290; female OR: 5.090); Model 4 (male OR: 3.256; female OR: 2.152)); long-lasting general health (Model 1 (female OR: 2.867); Model 3 (female OR: 3.602)); pulmonary diseases (Model 2 (male OR: 2.036); Model 4 (male OR: 1.976; female OR: 1.756)); musculoskeletal diseases (Model 1 (female OR: 1.537); Model 2 (male OR: 1.397; female OR: 1.410); Model 3 (male OR: 1.954; female OR: 1.739); Model 4 (male OR: 1.531; female OR: 1.483)); and other chronic diseases (Model 3 (male OR: 2.215)). Conclusions: Bad self-perceived general health and pulmonary and musculoskeletal diseases were predictors of functional disability in both genders of elderly individuals, while long-lasting health problems were predictors of functional disability in females and other chronic diseases were predictors in elderly males.

Association of fear of falling with performance-based physical function and low back pain in older adults: a cross-sectional study in Iran

OBJECTIVES

This study investigated the association of fear of falling with performance-based physical function and low back pain (LBP) among older adults.

DESIGN

Cross-sectional study.

SETTING

Participants were selected via convenient sampling from Iran University orthopaedic and/or physiotherapy outpatient clinics, between March 2022 and April 2023.

PARTICIPANTS

140 subjects with and without LBP, aged over 60 years, were included.

OUTCOME MEASURES

The Falls Efficacy Scale International was used to measure fear of falling. A baseline questionnaire inquired about LBP. Participants performed the Timed Up and Go, 30 s Sit-To-Stand (30s-STS), single leg stance with open and closed eyes and gait speed tests to assess performance-based physical function. Demographic variables including age, gender and body mass index were considered as potential covariates. Bivariate and multivariable linear regression analyses were used to investigate the associations.

RESULTS

A significant association between fear of falling and the 30s-STS test score (β=-0.30, 95% CI -1.27 to -0.28; p=0.00) and the sex (β=0.31, 95% CI 1.53 to 4.83; p=0.00) was confirmed in multivariable analyses. LBP and other performance-based physical function tests were not associated with a fear of falling.

CONCLUSION

Fear of falling was significantly associated with lower extremity muscle function, measured by the 30s-STS test and female gender. Older adults with a fear of falling could benefit from interventions that improve lower extremity muscle function. Also, the observed association between the fear of falling and the female sex confirms the need for effective interventions to reduce the fear of falling among older women.

A descriptive study of physical function and performance in older black men with low back pain

The purpose of this paper is to describe physical function and performance scores and examine the relationships between measures of physical performance in older Black men with low back pain. The Mobility, Aging, Pain, and Disparities study used a cross-sectional, observational design to objectively measure physical performance on the Short Physical Performance Battery (SPPB), the Back Performance Scale (BPS), and the 400-meter Walk Test along with subjective ratings of pain intensity in the past 24 hours. Sixty community-based Black men aged 61-87 (x̄= 70 ± 6) years had an average BPS score of 7.0 ± 4 and total score on the SPPB 8.5 ± 2.1. Average 400-meter Walk time was 6.3 ± 3.1 minutes. Men's average pain intensity in the past 24 hours was 5.7 ± 2, indicating moderate pain. In conclusion, older Black men with low back pain demonstrated low physical function scores and a higher level of disability.

The Chinese version of the Functionality Appreciation Scale: Psychometric properties and measurement invariance across gender and age

BACKGROUND

Functionality appreciation, as an important aspect of positive image, is associated with fewer body image disturbances, fewer disordered eating behaviors, and improved psychological well-being. However, it has been under-researched in Asian countries. The current work aimed to examine the psychometric properties of the Functionality Appreciation Scale (FAS) among four Chinese samples of different ages, and further examine measurement invariance and differences of the FAS across gender and age groups.

METHODS

Exploratory and confirmatory factor analyses (EFA and CFA) were conducted to examine the factorial structure of the FAS among four Chinese samples of different ages, including middle school adolescents (n = 894, M_age = 12.17 years), high school adolescents (n = 1347, M_age = 15.07 years), young adults (n = 473, M_age = 21.95 years), and older adults (n = 313, M_age = 67.90 years). The measurement invariance of the FAS across gender and age was examined. Internal consistency reliability and construct validity were evaluated.

RESULTS

The FAS had a unidimensional structure and was invariant across gender and age groups. The FAS presented sound psychometric properties in all age groups by gender, with good internal consistency reliability [e.g., high Cronbach's α values (.91 ~ .97)] and good construct validity (e.g., significant associations with body appreciation, body dissatisfaction, and disordered eating). Moreover, group comparisons showed minimal gender differences in functionality appreciation. However, significant age differences were found in functionality appreciation, with older ages generally associated with higher functionality appreciation.

CONCLUSION

Overall, findings suggest that the FAS is a sound instrument to be used in the Chinese context. Furthermore, functionality appreciation was found to be higher in older adults than adolescents or young adults, suggesting the potential important role of aging in functionality appreciation.

Catastrophic health expenditure among Chinese adults living alone with cognitive impairment: findings from the CHARLS

BACKGROUND

The catastrophic health expenditure of older adults results in serious consequences; however, the issue of whether cognitive status and living situations contribute to such financial burdens is uncertain. Our aim was to compare the differences in catastrophic health expenditure between adults living alone with cognitive impairment and those adults living with others and with normal cognition.

METHODS

We identified 909 observations of participants living alone with cognitive impairment (cases) and 37,432 observations of participants living with others and with normal cognition (comparators) from the 2011/2012, 2013, 2015 and 2018 waves of the China Health and Retirement Longitudinal Study (CHARLS). We used propensity score matching (1:2) to create matched cases and comparators in a covariate-adjusted logistic regression analysis. Catastrophic health expenditure was defined as an out-of-pocket cost for health care ≥40% of a household's capacity to pay.

RESULTS

In comparison with participants living with others and with normal cognition, those adults living alone with cognitive impairment reported a higher percentage of catastrophic health expenditure (19.5% vs. 11.8%, respectively, P < 0.001). When controlling for age, sex, education, marital status, residence areas, alcohol consumption, smoking status and disease counts, we found that this subpopulation had significantly higher odds of having catastrophic health expenditure (odds ratio [OR] = 1.89, 95% confidence interval [CI]: 1.40, 2.56). Additional analyses confirmed the robustness of the results.

CONCLUSIONS

This study demonstrated that adults living alone with cognitive impairment in the CHARLS experienced a high burden of catastrophic health expenditure. Health care policies on social health insurance and medical assistance should consider these vulnerable adults.

Screening for intrinsic capacity impairments as markers of increased risk of frailty and disability in the context of integrated care for older people: Secondary analysis of MAPT

AIM

This longitudinal secondary analysis of the Multidomain Alzheimer Preventive Trial (MAPT) aimed to test whether the Integrated Care for Older People (ICOPE) Step 1 screening tool is able to identify people at risk of developing frailty and disability in basic (ADL) and instrumental (IADL) activities of daily living among community-dwelling older adults.

PARTICIPANTS AND SETTING

Seven hundred and fifty-nine (n = 759) non-demented participants of the MAPT aged 70-89 years were assessed in memory clinics in France between 2008 and 2013.

METHODS

We measured six intrinsic capacity (IC) impairments, adapted from the ICOPE screening tool. We used Cox models to estimate the adjusted hazard ratios of incident frailty and IADL/ADL disability. Incident frailty was defined by Fried's phenotype, and incident disability was measured according to Lawton and Katz for IADLs and ADLs.

RESULTS

Limited mobility (HR= 2.97, 95%CI= 1.85-4.76), depressive symptoms (HR= 2.07, 95%CI= 1.03-4.19), and visual impairment (HR= 1.70, 95%CI 1.01-2.86) were associated with a higher incidence of frailty over 5 years. Each additional IC condition demonstrated a positive association with a higher risk of incident frailty, IADL, ADL disability, with risk increased by 47%, 27%, and 23% over 5 years, respectively.

CONCLUSION

Screening for IC impairments identifies older adults at higher risk of incident frailty and incident IADL/ADL disability. It is relevant to screen for these impairments together because the risk of frailty and disability increases with each additional one. ClinicalTrials.gov identifier: NCT00672685.

Disability trajectories in activities of daily living of elderly Chinese before death

This study aims to analyze the changes in activities of daily living (ADL) of the Chinese elderly before death, and to explore the heterogeneity in this process. Using data from the Chinese Longitudinal Healthy Longevity Survey (CLHLS), we quantify disability trajectories of ADL using a group-based trajectory model and find that there are three types of disability trajectory for ADL. The elderly who differ by socioeconomic status, childhood experiences, health behaviors, ages and birth cohorts show significant differences in their disability trajectories. Long duration of disability is found to be more prevalent in older females and people with high socioeconomic status. Good and stable status of ADL is more common among males and people of low socioeconomic status, while the elderly in an early cohort who died at older ages were more likely to have experienced a long duration of disability. Selective and protective effects contribute to the observed differences in trajectories.

Ethnic Differences in Functional Limitations by Age Across the Adult Life Course

Background

Despite compelling evidence from the United States of ethnic inequalities in physical functioning and ethnic differences in risk factors for poor physical functioning, very little is known about ethnic differences in the United Kingdom. Furthermore, the life stage at which these ethnic differentials are first observed has not been examined.

Methods

Using cross-sectional data from Wave 1 of the UK Household Longitudinal Study (UKHLS), we compared self-reported physical functioning among 35,816 White British, 4,450 South Asian and 2,512 African Caribbean men and women across different stages of adulthood (young adulthood, early middle age, late middle age, older age). Regression analyses examined ethnic differences in functional limitations, with adjustment for socioeconomic and clinical covariates. Ethnicity by sex and ethnicity by age-group interactions were examined, and subgroup heterogeneity was explored.

Results

Compared with White British adults over the age of 60, older South Asian men and women reported higher odds of functional limitations (odds ratio [OR] 2.77 [95% confidence interval {CI}: 2.00–3.89] and OR 3.99 [2.61–6.10], respectively); these ethnic differentials were observed as early as young adulthood. Young African Caribbean men had lower odds of functional limitations than White British men (OR 0.56 [0.34–0.94]), yet African Caribbean women reported higher odds of functional limitations in older age (OR 1.84 [1.21–2.79]).

Conclusions

There is an elevated risk of functional limitations relating to ethnicity, even in young adulthood where the impact on future health and socioeconomic position is considerable. When planning and delivering health care services to reduce ethnic inequalities in functional health, the intersectionality with age and sex should be considered.

Does a high-fat diet affect the development and progression of osteoarthritis in mice?: A systematic review

Aims

The aim of this study was to systematically review the literature for evidence of the effect of a high-fat diet (HFD) on the onset or progression of osteoarthritis (OA) in mice.

Methods

A literature search was performed in PubMed, Embase, Web of Science, and Scopus to find all studies on mice investigating the effects of HFD or Western-type diet on OA when compared with a control diet (CD). The primary outcome was the determination of cartilage loss and alteration. Secondary outcomes regarding local and systemic levels of proteins involved in inflammatory processes or cartilage metabolism were also examined when reported.

Results

In total, 14 publications met our inclusion criteria and were included in our review. Our meta-analysis showed that, when measured by the modified Mankin Histological-Histochemical Grading System, there was a significantly higher rate of OA in mice fed a HFD than in mice on a CD (standardized mean difference (SMD) 1.27, 95% confidence interval (CI) 0.63 to 1.91). Using the Osteoarthritis Research Society International (OARSI) score, there was a trend towards HFD causing OA (SMD 0.78, 95% CI -0.04 to 1.61). In terms of OA progression, a HFD consistently worsened the progression of surgically induced OA when compared with a CD. Finally, numerous inflammatory cytokines such as tumour necrosis factor alpha (TNF-α), interleukin (IL)-1β, and leptin, among others, were found to be altered by a HFD.

Conclusion

A HFD seems to induce or exacerbate the progression of OA in mice. The metabolic changes and systemic inflammation brought about by a HFD appear to be key players in the onset and progression of OA.

Cite this article:Bone Joint Res 2019;8:582–592.

Process of Decline in Activities of Daily Living of Older Chinese People Prior to Death: Evidence From Three Cohorts

Objective:

The study analyzes the decline in activities of daily living (ADL) prior to death among three cohorts of older Chinese.

Method:

With data from the Chinese Longitudinal Healthy Longevity Survey, the process of decline in ADL in older people born during the periods 1899–1908, 1909–1918, and 1919–1928 is analyzed using the hierarchical linear model with mixed effects.

Results:

The remaining survival time has a stronger effect on changes in ADL than chronological age, and there is significant heterogeneity among the older adults in ADL.

Conclusion:

Decline in ADL is delayed by extending life span. Older people with healthy behaviors, good living conditions in childhood, and age-friendly living environment have long-lasting good ADL during their remaining life span; socioeconomic resources help the older adults with ADL disabilities to survive. Selective effects of mortality and protective effects of socioeconomic resources explain the heterogeneity in ADL and its changes over time.

Disability Experience and Measurement

Top themes of international research on disability in the past three decades are discussed: disability dynamics, buffers and barriers for disability, disability trends, and disability among very old persons. Each theme is highlighted by research examples. Turning to measurement, I discuss traditional measures of disability, new longer and shorter ones, and composites like disability-free life expectancy, noting their merits. Contemporary models of disability are presented, ranging from visual images to formal theories. The article ends on how scientists can facilitate movement of disability science into health care practice and policy.

Resilience in context: the special case of advanced age

OBJECTIVES

Advanced age is a time shaped by the current experience of physical, social and psychological characteristics associated with living into an eighth decade and beyond and also by reflection upon past experiences. Understanding the specific factors that contribute to ageing well is increasingly important as greater numbers of older people remain living independently in the community and may require targeted and sustainable support to do so. This paper offers a conceptualisation of resilience for advanced age (age 85+), a life stage currently under-researched.

METHOD

We utilise a developmental and socio-historical context to develop key arguments about adversity, resources and positive outcomes that affect the experience of resilient ageing.

RESULTS

Very late life is characterised by a unique balance between losses, associated with vulnerability and resource restrictions, and potential gains based upon wisdom, experience, autonomy and accumulated systems of support, providing a specific context for the expression of resilience. Post-adversity growth is possible, but maintenance of everyday abilities may be more relevant to resilience in advanced age.

CONCLUSION

An increasing life-span globally necessitates creative and conscientious thought about wellbeing, and resilience research has the important aim to focus health and wellness on success and what is possible despite potential limitations.

Health Behaviors and Chronic Conditions Mediate the Protective Effects of Masculinity for Physical Performance in Older Adults

OBJECTIVE

We estimated the 2-year incidence of poor physical performance according to gender roles and examined mediating pathways related to health behaviors and chronic conditions.

METHOD

Data are from the International Mobility in Aging Study ( n = 1,676). The Bem Sex Role Inventory was used to classify participants into four gender roles as "masculine," "feminine," "androgynous," and "undifferentiated."

RESULTS

We found a higher incidence of poor physical performance among participants endorsing the feminine (adjusted incidence rate ratio [IRR] = 2.36, 95% confidence interval (CI) = [1.55, 3.60]) or the undifferentiated role (adjusted IRR = 2.19, 95% CI = [1.45, 3.30]) compared with the androgynous role. Smoking, physical activity, the number of chronic conditions, high body mass index, and depression were mediators of this association but not alcohol consumption.

DISCUSSION

This study provides evidence that gender roles are independently associated with physical performance. Health behaviors and chronic conditions are mediators of the relationship between gender roles and lower extremity physical function.

Longitudinal Relationships Between Productive Activities and Functional Health in Later Years

This study examined the longitudinal relationships between functional health in later years and three types of productive activities: volunteering, full-time, and part-time work. Using the data from five waves (2000–2008) of the Health and Retirement Study, we applied multivariate latent growth curve modeling to examine the longitudinal relationships among individuals 50 or over. Functional health was measured by limitations in activities of daily living. Individuals who volunteered, worked either full time or part time exhibited a slower decline in functional health than nonparticipants. Significant associations were also found between initial functional health and longitudinal changes in productive activity participation. This study provides additional support for the benefits of productive activities later in life; engagement in volunteering and employment are indeed associated with better functional health in middle and old age.

Factors associated with ADL/IADL disability in community dwelling older adults in the Irish longitudinal study on ageing (TILDA)

PURPOSE

To identify the factors associated with disability across many domains using a large powered sample in the activities of daily living (ADL) and instrumental activities of daily living (IADL).

METHODS

Those aged ≥65 years from the Irish longitudinal study on ageing (TILDA) were included in this cross sectional analysis. Three logistic regression models were used to examine the relationships between 25 health, psychological and sociodemographic variables and difficulties in ADL, IADL and ADL/IADL combined.

RESULTS

The proportion of those reporting combined ADL/IADL difficulties was 18%. More individuals reported difficulty with ADLs (13%) than IADLS (11%). The main model showed that after age, the top three factors associated with difficulty in ADL/IADL combined were pain, taking five or more medications and depression. After age, the factors with the highest impact on ADL disability were pain, taking five or more medications and body mass index (BMI); the factors with the highest impact on IADL were being separated or divorced, living with others (non-spouse) and self-rated memory.

CONCLUSIONS

Awareness of sociodemographics and early interventions for pain and cognitive deficits could reduce ADL/IADL disability and promote successful ageing. Identification of variables that influence ADL/IADLs can be used to inform policy and practice. Implications for rehabilitation After age, pain and taking five or more medications were the strongest factors associated with difficulty in ADL/IADL combined and ADL alone. Practice therefore needs to be cognizant that it is not the disease label but the symptoms of a disease that affect ADL and IADL activities. Given the strong influence of pain on difficulties with ADL and IADL, there is a need for early interventions from a multidisciplinary perspective for pain reduction, control, and self-management. These interventions should include development of pain-coping strategies and exercises to maintain mobility. After age, being separated/divorced or living with non-spouse others are the strongest factors associated with IADL difficulties. Awareness of these social factors can be used to inform support mechanisms, such as development of community services and suitable housing for those with these changing sociodemographics. Unsurprisingly, cognitive impairments were strongly associated with IADL difficulties. Simple cognitive screening assessments could be used for early detection of cognitive changes. In order to maintain optimal cognitive functioning, rehabilitation professionals should facilitate older adults' engagement in activities that are cognitively demanding and socially interactive.

Resistance training reduces disability in prostate cancer survivors on androgen deprivation therapy: evidence from a randomized controlled trial

OBJECTIVES

To investigate whether functionally based resistance exercise could improve strength, physical function, and disability among prostate cancer survivors (PCS) on androgen deprivation therapy (ADT); and to explore potential mediators of changes in outcomes from exercise.

DESIGN

Randomized controlled trial.

SETTING

Academic medical center.

PARTICIPANTS

PCS (N=51; mean age, 70.2y) on ADT.

INTERVENTION

PCS were randomized to moderate to vigorous intensity resistance training or stretching (placebo control) for 1 year.

MAIN OUTCOME MEASURES

Maximal leg press and bench press strength, objective and self-reported physical function, and self-reported disability. Hierarchical linear modeling was used to test for significant group × time differences adjusting for covariates.

RESULTS

Retention in the study was 84%, and median attendance to supervised classes was 84% in the resistance group. No study-related injuries occurred. Maximal leg strength (P=.032) and bench press strength (P=.027) were improved after 1 year of resistance training, whereas little change occurred from stretching. Self-reported physical function improved with resistance training, whereas decreases occurred from stretching (P=.016). Disability lessened more with resistance training than stretching (P=.018). One-year change in leg press strength mediated the relation between groups (resistance or stretching) and 1-year change in self-reported disability (P<.05).

CONCLUSIONS

One year of resistance training improved muscle strength in androgen-deprived PCS. Strengthening muscles using functional movement patterns may be an important feature of exercise programs designed to improve perceptions of physical function and disability. Findings from this study contribute to the mounting evidence that exercise should become a routine part of clinical care in older men with advanced prostate cancer.

Trends and variation in mild disability and functional limitations among older adults in Norway, 1986-2008

An increase in the number of older adults may raise the demand for health and care services, whereas decreasing prevalence of disability and functional limitations among them might counteract this demographic effect. However, the trends in health are inconsistent between studies and countries. In this article, we estimated the trends in mild disability and functional limitations among older Norwegians and analyzed whether they differ between socio-demographic groups. Data were obtained from repeated cross-sectional surveys conducted in 1987, 1991, 1995, 2002, 2005, and 2008, in total 4,036 non-institutionalized persons aged 67 years or older. We analyzed trends using multivariate logistic regression. On average, the age-adjusted trend in functional limitations was −3.3% per year, and in disability 3.4% per year. The risk for functional limitations or disability was elevated for women compared to men, for married compared to non-married, and was inversely associated with educational level The trends were significantly weaker with increasing age for disabilities, whereas none of the trends differed significantly between subgroups of sexes, educational level or marital status. Both functional limitations free and disability-free life expectancy appeared to have increased more than total life expectancy at age 67 during this period. The analysis suggests downward trends in the prevalence of mild disability and functional limitations among older Norwegians between 1987 and 2008 and a compression of lifetime in such health states. The reduced numbers of older people with disability and functional limitations may have restrained the demand for health and care services caused by the increase in the number of older adults.

The effect of having a partner on activities of daily living in men and women aged 82-87 years

BACKGROUND

Physical functioning is an important determinant of mortality and morbidity in older adults and there may be differences by gender and marital status. This study compared disability, measured by the ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs), between older men and women who are either partnered or not partnered.

METHODS

Participants included 5497 women and 1072 men aged 82-87 years from cross sectional surveys conducted in 2008 (the Health in Men Study and the Australian Longitudinal Study on Women's Health). Ordinal logistic regression was used to examine the relationship between disability and gender by marital status, adjusting for self-reported chronic conditions.

RESULTS

Women reported a higher prevalence of most chronic conditions than men. Unpartnered men had significantly higher odds of reporting difficulty in dressing the lower body and doing heavy housework, and significantly lower odds of reporting difficulty managing money and preparing meals than partnered men. Unpartnered and partnered women had significantly lower odds of reporting difficulty in dressing the lower body, walking inside the house, using the toilet, preparing meals, taking medications, using the telephone and performing leisure activities than partnered men. However, unpartnered and partnered women had significantly higher odds of reporting difficulty with eating, shopping, and doing light or heavy housework than did partnered men.

CONCLUSIONS

Differences between partnered and unpartnered older men and women in difficulty with ADLs and IADLs were identified, with women reporting less difficulty overall, regardless of partner status.

Health promotion needs of physically disabled individuals with lower limb amputation in Rwanda

PURPOSE

The objectives of the study were to identify the health-related behaviors among physically disabled individuals with lower limb amputation resident in Rwanda, the factors that influenced these behaviors, and the major issues that should be targeted in health promotion programs for physically disabled individuals with lower limb amputation.

METHOD

A cross-sectional survey, utilizing a self-administered questionnaire, was carried out among 334 lower limb amputees who volunteered to take part in the study. In addition, a sub-sample of 15 participants was purposely selected for in-depth face-to-face interviews.

RESULTS

Many participants did not engage in physical exercises (64.7%). Others abused alcohol on daily basis (14.4%), smoked 11-20 cigarettes daily (13.2%), and used recreational drugs such as marijuana, opium and cocaine (9.6%). There were significant associations between the age group of the participants and participation in exercises (P=0.001), and consuming alcohol, tobacco and recreational drugs (P=0.001). In-depth interviews revealed factors influencing the behavior of participants.

CONCLUSIONS

Participants were found to be at risk of secondary complications because of poor lifestyle choices. There is a need to develop and promote wellness-enhancing behaviors in order to enhance the health status of physically disabled individuals in Rwanda who have lower limb amputations.

Perceived neighborhood safety and incident mobility disability among elders: the hazards of poverty

BACKGROUND

We investigated whether lack of perceived neighborhood safety due to crime, or living in high crime neighborhoods was associated with incident mobility disability in elderly populations. We hypothesized that low-income elders and elders at retirement age (65 - 74) would be at greatest risk of mobility disability onset in the face of perceived or measured crime-related safety hazards.

METHODS

We conducted the study in the New Haven Established Populations for Epidemiologic Studies of the Elderly (EPESE), a longitudinal cohort study of community-dwelling elders aged 65 and older who were residents of New Haven, Connecticut in 1982. Elders were interviewed beginning in 1982 to assess mobility (ability to climb stairs and walk a half mile), perceptions of their neighborhood safety due to crime, annual household income, lifestyle characteristics (smoking, alcohol use, physical activity), and the presence of chronic co-morbid conditions. Additionally, we collected baseline data on neighborhood crime events from the New Haven Register newspaper in 1982 to measure local area crime rates at the census tract level.

RESULTS

At baseline in 1982, 1,884 elders were without mobility disability. After 8 years of follow-up, perceiving safety hazards was associated with increased risk of mobility disability among elders at retirement age whose incomes were below the federal poverty line (HR 1.56, 95% CI 1.02 - 2.37). No effect of perceived safety hazards was found among elders at retirement age whose incomes were above the poverty line. No effect of living in neighborhoods with high crime rates (measured by newspaper reports) was found in any sub-group.

CONCLUSION

Perceiving a safety hazard due to neighborhood crime was associated with increased risk of incident mobility disability among impoverished elders near retirement age. Consistent with prior literature, retirement age appears to be a vulnerable period with respect to the effect of neighborhood conditions on elder health. Community violence prevention activities should address perceived safety among vulnerable populations, such as low-income elders at retirement age, to reduce future risks of mobility disability.

Perceived neighborhood safety and incident mobility disability among elders: the hazards of poverty

BACKGROUND

We investigated whether lack of perceived neighborhood safety due to crime, or living in high crime neighborhoods was associated with incident mobility disability in elderly populations. We hypothesized that low-income elders and elders at retirement age (65 - 74) would be at greatest risk of mobility disability onset in the face of perceived or measured crime-related safety hazards.

METHODS

We conducted the study in the New Haven Established Populations for Epidemiologic Studies of the Elderly (EPESE), a longitudinal cohort study of community-dwelling elders aged 65 and older who were residents of New Haven, Connecticut in 1982. Elders were interviewed beginning in 1982 to assess mobility (ability to climb stairs and walk a half mile), perceptions of their neighborhood safety due to crime, annual household income, lifestyle characteristics (smoking, alcohol use, physical activity), and the presence of chronic co-morbid conditions. Additionally, we collected baseline data on neighborhood crime events from the New Haven Register newspaper in 1982 to measure local area crime rates at the census tract level.

RESULTS

At baseline in 1982, 1,884 elders were without mobility disability. After 8 years of follow-up, perceiving safety hazards was associated with increased risk of mobility disability among elders at retirement age whose incomes were below the federal poverty line (HR 1.56, 95% CI 1.02 - 2.37). No effect of perceived safety hazards was found among elders at retirement age whose incomes were above the poverty line. No effect of living in neighborhoods with high crime rates (measured by newspaper reports) was found in any sub-group.

CONCLUSION

Perceiving a safety hazard due to neighborhood crime was associated with increased risk of incident mobility disability among impoverished elders near retirement age. Consistent with prior literature, retirement age appears to be a vulnerable period with respect to the effect of neighborhood conditions on elder health. Community violence prevention activities should address perceived safety among vulnerable populations, such as low-income elders at retirement age, to reduce future risks of mobility disability.

Factors associated with frailty in chronically ill older adults

An ex post facto analysis of a secondary dataset examined relationships between physical frailty, depression, and the self-perceived domains of health status and quality-of-life in older adults. The randomized sample included 992 community-dwelling, chronically ill, and functionally impaired adults age 65 and older who received care from a Southern California Kaiser Permanente medical center between 1998 and 2002. Physical frailty represents a level of physiologic vulnerability and functional loss that results in dependence on others for basic, daily living needs (Fried et al., 2001). The purpose of the study was to identify possible intervention junctures related to self-efficacy of older adults in order to help optimize their functionality. Multivariate correlation analyses showed statistically significant positive correlations between frailty level and depression (r = .18; p = < .05), number of medical conditions (r = .09; p = < .05), and self-rated quality-of-life (r = .24; p = < .05). Frailty level showed a statistically significant negative correlation with self-perceived health status (r = -.25; p = < .05). Notably, no statistically significant correlation was found between age and frailty level (r = -.03; p = < .05). In linear regression, self-perceived health status had a partial variance with frailty level (part r = -.18). The significant correlations found support further research to identify interventions to help vulnerable, older adults challenge self-perceived capabilities so that they may achieve optimum functionality through increased physical activity earlier on, and increased self-efficacy to support successful adaptation to aging-related losses.

Depression in older people: visual impairment and subjective ratings of health

PURPOSE

The aim of this study was to establish the prevalence of depression in a sample of older adults with impaired vision and investigate associations between physical and visual disability and depression.

METHODS

We analyzed cross-sectional baseline data from 391 participants aged >or=75 years with visual acuity of 6/24 (20/80) or less, recruited for a randomized controlled trial of interventions to prevent falls (the VIP trial). Measures included the geriatric depression scale (GDS-15), the state-trait anxiety index, activities of daily living (Nottingham extended ADL scale), physical activity (human activity profile), an index of visual functioning (VF-14), health-related quality of life (SF-36), objective measures of physical ability, and a measure of visual acuity. Regression models were developed to investigate the association between depression scores and physical, psychological, and visual disability.

RESULTS

About 29.4% (115 of 391) of participants were identified as potentially depressed (GDS-15 score >4). Physical function, physical activity, physical ability, visual function, anxiety, and self-reported physical and mental health were significantly worse for those with depressive symptomatology. Physical, visual, and psychological factors collectively explained 41% of the variance in the depression score in a linear regression model (R=0.421, adjusted R=0.410, F (7,382)=39.680, p<0.001). Depression was not related to age, gender, living situation, ethnicity, or number of prescription or antidepressant medications taken.

CONCLUSIONS

Depression was common in this population of older adults with severe visual impairment. Impaired visual and physical functions were associated with symptoms of depression. The effect of visual disability was independent of the effect of physical disability. The strength of this relationship, and the results of the regression analyses, indicate that a person who is visually or physically disabled is more likely to suffer from depression.

Muscle quality, aerobic fitness and fat mass predict lower-extremity physical function in community-dwelling older adults

BACKGROUND

Muscle mass, strength and fitness play a role in lower-extremity physical function (LEPF) in older adults; however, the relationships remain inadequately characterized.

OBJECTIVE

This study aimed to examine the relationships between leg mineral free lean mass (MFLM(LEG)), leg muscle quality (leg strength normalized for MFLM(LEG)), adiposity, aerobic fitness and LEPF in community-dwelling healthy elderly subjects.

METHODS

Fifty-five older adults (69.3 +/- 5.5 years, 36 females, 19 males) were assessed for leg strength using an isokinetic dynamometer, body composition by dual energy X-ray absorptiometry and aerobic fitness via a treadmill maximal oxygen consumption test. LEPF was assessed using computerized dynamic posturography and stair ascent/descent, a timed up-and-go task and a 7-meter walk with and without an obstacle.

RESULTS

Muscle strength, muscle quality and aerobic fitness were similarly correlated with static LEPF tests (r range 0.27-0.40, p < 0.05); however, the strength of the independent predictors was not robust with explained variance ranging from 9 to 16%. Muscle quality was the strongest correlate of all dynamic LEPF tests (r range 0.54-0.65, p < 0.001). Using stepwise linear regression analysis, muscle quality was the strongest independent predictor of dynamic physical function explaining 29-42% of the variance (p < 0.001), whereas aerobic fitness or body fat mass explained 5-6% of the variance (p < 0.05) depending on performance measure.

CONCLUSIONS

Muscle quality is the most important predictor, and aerobic fitness and fat mass are secondary predictors of LEPF in community-dwelling older adults. These findings support the importance of exercise, especially strength training, for optimal body composition, and maintenance of strength and physical function in older adults.

Chronic disease self-management program for low back pain in the elderly

OBJECTIVE

To evaluate the effectiveness of Stanford's Chronic Disease Self-Management Program (CDSMP) for chronic low back pain (LBP) in older Americans.

DESIGN

Randomized controlled trial.

SETTING

Community-based program offered at 12 locations.

SUBJECTS

Community-dwelling seniors (n = 109) aged 60 and older with chronic LBP of mechanical origin.

METHODS

Patients were randomly allocated to the CDSMP or to a 6-month, wait-list control group. The program included one 2.5-hour session per week for 6 weeks. Outcomes evaluated at 6 months included 100-point modified Von Korff pain and disability scales; days with pain and disability; SF-36 general health, energy-fatigue, and emotional well-being scales; 2 scales from the Arthritis Self-Efficacy Scale, self-care attitudes/behaviors, and health services utilization.

RESULTS

For pain at 6 months, the primary outcome, the adjusted mean difference between the program and control, was -1.0 (P = .835). There was a sizable advantage for the program in disability averaged over the course of the entire 6-month study (-9.2, P = .027), but not at the 6-month follow-up (-5.8, P = .278). There was an interaction between intervention and baseline disability days favoring the program for higher baseline values (P = .007). The CDSMP affected emotional well-being (7.6, P = .037) and energy-fatigue (5.1, P = .274). There were no differences for self-efficacy, pain days, and general health.

CONCLUSION

There was no advantage for the CDSMP over a wait-list control for improving pain, general health, self-efficacy, and self-care attitudes in older Americans with chronic LBP. A benefit was suggested for emotional well-being, fatigue, functional disability, and days with disability.

Screening, safety, and adverse events in physical activity interventions: Collaborative experiences from the behavior change consortium

Researchers who conduct physical activity (PA) intervention studies provide an invaluable opportunity to further the prevention science knowledge base for implementing and delivering PA programs. Despite recommendations that screening is important to increase patient safety, the specific screening criteria best suited for different community applications are unknown. To add to the limited knowledge base, we examined the screening procedures and the occurrence of adverse events among more than 5,500 participants from 11 diverse PA interventions participating in a trans-National Institutes of Health (NIH) collaborative known as the Behavior Change Consortium (BCC). Numerous adverse events occur in sedentary, chronically ill, or older populations, although few are attributed to activity/exercise interventions. No serious study-related adverse events (SRAEs) were reported across different screening practices, interventions, and/or populations. Relatively few minor SRAEs were reported (primarily musculoskeletal injuries), emphasizing the need to be aware of potential musculoskeletal sequelae during exercise interventions. One common characteristic of these studies is that they recommended "start low and go slow" strategies, with moderate intensity PA as the goal behavior. Recommendations to reframe the meaning and use of screening criteria to initiate PA in the community are discussed. Although we were unable to conduct generalizable quantitative analyses from our data, the combined experience of the BCC studies provides a unique opportunity to examine PA-related screening and safety issues across diverse populations, settings, and intervention programs.

Self-reported health complaints and their prediction of overall and health-related quality of life among elderly people

OBJECTIVE

To describe and compare self-reported health complaints, overall and health-related quality of life and to investigate how health complaints, age, gender, marital status, living and dwelling conditions and socio-economy predicted overall and health-related quality of life.

DATA AND METHOD

A sample of 469 persons (aged 75-99) responded to a postal questionnaire. Multiple linear regression analysis was used to examine possible predictors.

RESULT

Self-reported health complaints such as pain, fatigue and mobility impairment significantly predicted low overall and health-related quality life. Women had significantly lower overall and health-related quality of life than men, and a significantly higher degree of self-reported health complaints. The regression models had more similarities than differences, implying that the overall quality of life instrument were sensitive to physical influences only supposed to be detected by health-related quality of life instruments. Several of the health complaints predicting low quality of life are amenable for being relieved by nursing care. In the care of older people nurses need to assess for several health complaints simultaneously and be aware of their possible interaction when outlining interventions. Nurses are able to facilitate early detection of health complaints negatively affecting quality of life by implementing more pro-active preventive work as well as a higher degree of thorough and systematic assessments. It also seems important to consider that older woman's and men's needs for high quality of life may differ.

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.

Age- and sex-stratified prevalence of physical disabilities and handicap in the general population

BACKGROUND AND AIMS

Our aim was to provide age- and sex-stratified prevalence estimates of physical disabilities and handicap in the general Belgian population.

METHODS

A cross-sectional and demographically representative health interview survey was conducted nationwide in Belgium in 1997. The 8836 persons aged 15 years and over who answered the health interview were included in this study. Seventeen items from the survey encompassing main activities of daily living (ADL) and confining were analyzed. To provide prevalence estimates as detailed as possible, neither aggregation nor dichotomization were applied.

RESULTS

Women consistently reported more disability than men: mobility (p < 0.001), transfer in-out bed (p < 0.001), transfer in-out chair (p < 0.001), dressing (p = 0.004), washing hands and face (p = 0.029), getting to and using toilet (p = 0.003), continence (p < 0.001), seeing (p < 0.001) and mastication (p < 0.001). As expected, there was a marked trend for increased prevalence of disability with increasing age for both sexes. Moderate disability arose mainly from the 25-34 age group for both sexes. For both genders, severe disability appeared mainly at higher ages, particularly for the 65-74 age group. Nevertheless, the data suggest that continence problems for women, mobility and transfer issues for men, as well as mastication problems for both genders, clearly emerge earlier than age 65. Regarding handicap, observed prevalence rates were increasing, in age as was the case for disability, but no differences were found between men or women, except for confinement to house/garden, for which women presented a higher rate in general (p < 0.001) and in the 75-84 age group (p = 0.036) in particular.

CONCLUSIONS

This study shows the wide range of disability types in the general population and their association with handicap. While elderly individuals consistently report higher degrees of disability and handicap, attention should also be paid to younger age groups. Disability calls for wide, coherent and relevant medical as well as social responses.

Disability predicted mortality in men but not women with coronary heart disease

OBJECTIVE

Disability increases mortality in patients with myocardial infarction in acute clinical settings, but the impact of disability on mortality in persons with coronary heart disease (CHD) at the population level is largely unknown.

STUDY DESIGN AND SETTING

We assessed disability as a predictor of mortality among 4,501 men and women aged 45 and over in a national sample of the Finnish population, examined in 1978-1980.

RESULTS

During follow-up until the end of 1994, 897 men and 846 women died. Disability was related to increased all-cause and CHD mortality after adjustment for cardiovascular risk factors in men regardless of baseline CHD status. In women with CHD at baseline, disability was not related to excess mortality, although disability predicted mortality in women without baseline CHD.

CONCLUSION

Disability predicts mortality in men with CHD, but not in women. This may reflect a gender difference in the nature of CHD, but these findings need to be verified in other large-scale population studies.

The Israeli kibbutz as a venue for reduced disability in old age: lessons from the Cross-sectional And Longitudinal Aging Study (CALAS)

It is important to identify ways to moderate disability in old age. We assessed whether the kibbutz way of life results in reduced disability by examining risk factors for disability in three comparable populations: kibbutz members (lifetime kibbutz exposure); parents of kibbutz members who came to live on the kibbutz in old age due to health and social needs (old age exposure); and comparable Israelis in the general population (no exposure). Kibbutz members were less disabled, defined as needing help with at least one of five activities of daily living, than the other groups. Kibbutz members had 30% lower risk of disability, after controlling for sociodemographics and social networks, health and health behaviors, and life history and background. Introducing length of residence in current home and death of a child to the analysis reduced this finding to non-significance. Overall, risk of disability was significantly higher for older age groups, women, homemakers, people with more comorbid conditions, those with more children, and those with a child that had died, while risk of disability was significantly lower for those with larger social networks, those who had engaged in physical activity at midlife, and those who had lived in their homes longer. Since occupations on the kibbutz (primarily agricultural and blue collar) have equal pay, and kibbutz members have complete economic security, our results suggest that it is not such occupations themselves but their association with low incomes that have contributed to previous associations of blue collar and agricultural occupations with poor health and high disability. Lower disability among kibbutz members may be due to the social, economic, and instrumental support provided on the kibbutz, as well as to an active life style, suggesting features of kibbutz life that can be replicated elsewhere to reduce disability.

Positive affect and disability among older Mexican Americans with arthritis

OBJECTIVE

To examine the relationship between positive affect and subsequent functional disability in older Mexican Americans with self-reported physician-diagnosed arthritis.

METHODS

We conducted a 2-year prospective cohort study using a population-based sample of 1,084 noninstitutionalized Mexican American subjects aged > or =65 years residing in 5 southwestern states. Measures included self-reported diagnoses of various medical conditions, functional ability, body mass index, and ratings of positive and negative affect.

RESULTS

For 937 subjects with arthritis who reported no limitations in activities of daily living (ADLs) at baseline, 697 remained ADL independent, 84 became ADL dependent, 41 died, and 115 were lost to followup 2 years later. There was a significant association between high positive affect (score = 12) and reduced risk of ADL disability 2 years later, controlling for baseline sociodemographic variables, medical conditions, and negative affect (odds ratio 0.46, 95% confidence interval 0.22-0.94). There was an interaction effect between positive affect and sex, with positive affect having a larger effect in reducing risk of ADL dependence in men than in women.

CONCLUSION

High positive affect was associated with lower incidence of ADL disability in older Mexican Americans with self-reported physician-diagnosed arthritis. The strength of the positive affect is stronger in men than in women.

Reliability and validity of the Functional Rating Index in older people with low back pain: preliminary report

BACKGROUND AND AIMS

The Functional Rating Index (FRI) was developed to provide an assessment instrument which has not only clinical usefulness but also quantifies the patient's current state of pain and dysfunction in a reliable and valid manner for spinal conditions. There is no study on the FRI applied to older people with low back pain (LBP). The primary aim of this study was to evaluate the validity and reliability of the FRI in older people with LBP.

METHODS

A total of 76 subjects aged 65 to 90 years with LBP, of which 37 were cognitively intact and were followed up on a second occasion, were assessed by the FRI, numeric rating scale (NRS), Roland Morris Questionnaire (RMQ) and spinal movement test. Reliability was assessed by statistical analysis of test results for test-retest and internal consistency. To assess construct validity, the FRI was compared with the RMQ. Concurrent validity was assessed using the NRS and spinal mobility test.

RESULTS

The FRI demonstrated high internal consistency, with alpha=0.921 for test and alpha=0.901 for retest. Item-scale correlations were between 0.549-0.871. Test-retest correlation was 0.913 (p=0.000). There was very good construct validity between the FRI and the RMQ for test (r=0.663, p<0.000) and retest (r=0.603, p<0.000). The FRI showed high correlation with the NRS (r=0.701, p<0.000 for test; r=0.743, p<0.000 for retest) and no correlation with the spinal movement test (r=0.173, p=0.307 for test; r=0.024, p=0.888 for retest).

CONCLUSIONS

In this preliminary report, the FRI appears to be easy to administer, seems to have significant validity and reliability, and may be useful in geriatric assessment of older people with LBP.

Waist circumference and weight change are associated with disability among elderly Hispanics

BACKGROUND

Studies have suggested that both high and low body mass index (BMI) and weight change are related to functional disability in elderly populations. Elderly Hispanics have a high prevalence of both obesity and disability, yet few studies have examined their interrelationship in this population. Therefore, we examined these relationships in a mostly Puerto Rican group of Hispanic elders.

METHODS

We investigated associations between a three-level disability score created from responses to a questionnaire on activities of daily living and BMI, waist circumference (WC), and weight change since age 50, using the proportional odds model in a cross-sectional study of 763 elderly Hispanics, aged 60 to 92 years, residing in Massachusetts.

RESULTS

After adjusting for potential confounders, men with a WC > or =109.3 cm (vs <90 cm), or with a reported weight loss of -0.32 to -0.01 kg/year, or a weight gain > or =0.55 kg/year since age 50 (vs relatively stable weight, -0.01 to +0.21 kg/year [y]) were each significantly associated with an approximately threefold higher risk for greater disability. Women with a BMI > or =35 kg/m(2) were almost four times as likely to have higher disability as those with a BMI of 20 to 25 kg/m(2). Compared with women with a WC < or =85.2 cm, those with a WC of 91.5 to 106.6 cm were two times more likely, and those with a WC > or =106.6 cm were five times more likely, to have higher disability scores. Compared with relatively stable weight (-0.05 to +0.23 kg/y), weight gain > or =0.23 kg/year was associated with a twofold higher risk of greater disability among women. When BMI and WC were included in the same model, WC, but not BMI, remained significantly associated with disability.

CONCLUSIONS

Abdominal obesity (WC > or =109.3 cm for men, or WC > or =91.5 cm for women) and weight gain > or =0.55 kg/year after age 50 in men or > or =0.23 kg/year in women may increase the risk of disability among elderly Hispanics.

Construct validation and test-retest reliability of the seniors in the community: risk evaluation for eating and nutrition questionnaire

BACKGROUND

We performed two studies. Study 1 was a construct validation of Seniors in the Community: Risk Evaluation for Eating and Nutrition (SCREEN), a 15-item questionnaire for assessing nutritional risk. In Study 2, we examined the test-retest reliability of SCREEN.

METHODS

Study 1 was a cross-sectional study, and Study 2 was a cohort study. For Study 1, ten diverse community sites were used to recruit participants. A total of 128 older adults attended a clinic to provide medical and nutritional history and anthropometric measurements. A dietitian interviewed each participant. Dietitians used clinical judgment to rate the probability of nutritional risk from 1 (low risk) to 10 (high risk). Spearman's rho correlation and receiver operating characteristic curves were completed. An abbreviated SCREEN was developed through multiple linear regression analysis. In Study 2, SCREEN was randomly distributed to members of a seniors' recreation center where a self-selected sample (n = 124) completed two mailed SCREENs, 4 weeks apart. The test-retest reliability was estimated through paired correlations of total scores and individual items.

RESULTS

In Study 1, total and abbreviated SCREEN scores were significantly associated with the dietitian nutritional risk rating (rho = -.47 and rho = -.60, respectively). Study 2 revealed that the test-retest reliability of SCREEN was adequate.

CONCLUSIONS

SCREEN appears to be a valid and reliable tool for identifying community-dwelling older adults at risk for impaired nutritional states.

Balance, mobility, and falls among elderly African American women

OBJECTIVE

To compare balance, mobility, recent falls, and injuries among elderly African American and white women.

DESIGN

This was a nonexperimental study. Participants, who were older than 65 yr of age, able to walk at least 30 ft, not residing in a nursing home, and with no acute medical problems, were recruited from 17 senior citizens' community centers.

RESULTS

Compared with white women (n=180), African American women (n = 118) took fewer medications, had greater body mass indexes, had less muscle strength, and had more medical conditions and neurologic abnormalities. Additionally, these women were less active and had poorer performances on an obstacle course. The two groups had a similar histories of falls and injuries. For both groups, activity level and neurologic findings were predictors of obstacle course performance. For white women, muscle strength was an additional predictor of obstacle course performance. An additional predictor for African American women was range of motion.

CONCLUSION

The poorer balance and mobility of African American women compared with white women may have consequences such as their functional dependence, resulting in their greater use of hospitals and formal and informal health services.

Disability in older adults. 3: Policy implications

Several models of disability proposed in recent years share many common elements and are helping to direct research and inform practice. One new development is that disablement, a concept that emphasizes the impairments--handicap continuum, is now being implemented by concepts related to enablement. Enablement focuses attention on the capacity for rehabilitation. Coincidentally, a new generation of functional assessment measures has evolved that allow greater sensitivity not only to levels of disability but also to levels of ability. Together, the new models and tools hold promise of providing a more sensitive evaluation of rehabilitation efforts and a more accurate forecasting of future needs.