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Journal ArticleDOI

Instrumental Activities of Daily Living as a Potential Marker of Frailty A Study of 7364 Community-Dwelling Elderly Women (the EPIDOS Study)

01 Jul 2001-Journals of Gerontology Series A-biological Sciences and Medical Sciences (Oxford University Press)-Vol. 56, Iss: 7

TL;DR: The results confirmed that women with disability on at least one IADL item are frailer because they had more associated disorders, poorer cognitive function and more frequent falls.

AbstractBackground. A number of clinical conditions have been shown to be associated with frailty in elderly people. We hypothesized that incapacities on the Instrumental Activities of Daily Living (IADLs) scale could make it possible to identify this population. We investigated the associations between IADL incapacities and the various known correlates of frailty in a cohort of community-dwelling elderly women. Methods. Cross-sectional analysis was carried out on the data from 7364 women aged over 75 years (EPIDOS Study). The IADL was the dependent variable. Sociodemographic, medical, and psychological performance measures were obtained during an assessment visit. Falls in the previous 6 months and fear of falling were also ascertained. Body composition was measured by dual-energy x-ray absorptiometry. The factors associated with disability in at least one IADL were included in a logistic regression model. Results. Thirty-two percent of the population studied had disability in at least one IADL item. This group was significantly older (81.7 � 4.1 yr vs 79.8 � 3.4 yr), had more frequent histories of heart disease, stroke, depression or diabetes, and was socially less active ( p � .001). These associations persisted after multivariate analysis. Cognitive impairment as assessed by the Pfeiffer test (Pfeiffer score � 8) was closely associated with disabilities on the IADL (OR 3.101, 95% confidence interval [CI] 2.19‐4.38). Falls and fear of falling were also more frequent in the group of women with an abnormal IADL ( p � .001) but only fear of falling remained significantly associated with incapacities on at least one IADL item after logistic regression (OR 1.47, 95% CI 1.28‐1.69). Women with disability on at least one IADL item also had lower bone mineral density, this was independent of the other factors. Conclusion. Our results confirmed that women with disability on at least one IADL item are frailer because they had more associated disorders, poorer cognitive function and more frequent falls. Disabilities on this scale could be a good tool for identifying individuals at risk of frailty among elderly persons living at home and in apparent good health. This finding requires confirmation by longitudinal studies.

Topics: Fear of falling (54%), Population (52%), Activities of daily living (50%)

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Citations
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Journal ArticleDOI
TL;DR: The ability of the Clinical Frailty Scale to predict death or need for institutional care, and correlated the results with those obtained from other established tools are determined.
Abstract: Background: There is no single generally accepted clinical definition of frailty. Previously developed tools to assess frailty that have been shown to be predictive of death or need for entry into an institutional facility have not gained acceptance among practising clinicians. We aimed to develop a tool that would be both predictive and easy to use. Methods: We developed the 7-point Clinical Frailty Scale and applied it and other established tools that measure frailty to 2305 elderly patients who participated in the second stage of the Canadian Study of Health and Aging (CSHA). We followed this cohort prospectively; after 5 years, we determined the ability of the Clinical Frailty Scale to predict death or need for institutional care, and correlated the results with those obtained from other established tools. Results: The CSHA Clinical Frailty Scale was highly correlated ( r = 0.80) with the Frailty Index. Each 1-category increment of our scale significantly increased the medium-term risks of death (21.2% within about 70 mo, 95% confidence interval [CI] 12.5%–30.6%) and entry into an institution (23.9%, 95% CI 8.8%–41.2%) in multivariable models that adjusted for age, sex and education. Analyses of receiver operating characteristic curves showed that our Clinical Frailty Scale performed better than measures of cognition, function or comorbidity in assessing risk for death (area under the curve 0.77 for 18-month and 0.70 for 70-month mortality). Interpretation: Frailty is a valid and clinically important construct that is recognizable by physicians. Clinical judgments about frailty can yield useful predictive information.

4,025 citations


Journal ArticleDOI
TL;DR: The frailty definition developed in the CHS is applicable across diverse population samples and identifies a profile of high risk of multiple adverse outcomes and is consistent with the widely held theory that conceptualizes frailty as a syndrome.
Abstract: Background "Frailty" is an adverse, primarily gerontologic, health condition regarded as frequent with aging and having severe consequences. Although clinicians claim that the extremes of frailty can be easily recognized, a standardized definition of frailty has proved elusive until recently. This article evaluates the cross-validity, criterion validity, and internal validity in the Women's Health and Aging Studies (WHAS) of a discrete measure of frailty recently validated in the Cardiovascular Health Study (CHS). Methods The frailty measure developed in CHS was delineated in the WHAS data sets. Using latent class analysis, we evaluated whether criteria composing the measure aggregate into a syndrome. We verified the criterion validity of the measure by testing whether participants defined as frail were more likely than others to develop adverse geriatric outcomes or to die. Results The distributions of frailty in the WHAS and CHS were comparable. In latent class analyses, the measures demonstrated strong internal validity vis a vis stated theory characterizing frailty as a medical syndrome. In proportional hazards models, frail women had a higher risk of developing activities of daily living (ADL) and/or instrumental ADL disability, institutionalization, and death, independently of multiple potentially confounding factors. Conclusions The findings of this study are consistent with the widely held theory that conceptualizes frailty as a syndrome. The frailty definition developed in the CHS is applicable across diverse population samples and identifies a profile of high risk of multiple adverse outcomes.

1,005 citations


Cites background from "Instrumental Activities of Daily Li..."

  • ...There have been proposals to identify older adults who are frail, or at risk for frailty, by their disability status (9), functional performance (10), or a combination of either with comorbidity, neurosensory problems, or adverse geriatric out-...

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Journal ArticleDOI
01 Sep 2005-Stroke
TL;DR: A growing body of evidence indicates that patients do better with a well-organized, multidisciplinary approach to post-acute rehabilitation after a stroke, and greater adherence to post–acute stroke rehabilitation guidelines was associated with improved patient outcomes.
Abstract: Stroke is a leading cause of disability in the United States.1 The Veterans Health Administration (VHA) of the Department of Veterans Affairs (VA) estimates that 15 000 veterans are hospitalized for stroke each year (VA HSR&D, 1997). Forty percent of stroke patients are left with moderate functional impairments and 15% to 30% with severe disability.2 Effective rehabilitation interventions initiated early after stroke can enhance the recovery process and minimize functional disability. Improved functional outcomes for patients also contribute to patient satisfaction and reduce potential costly long-term care expenditures. There are only 45 rehabilitation bed units (RBUs) in the VA today. Many veterans who have a stroke and are admitted to a VA Medical Center will find themselves in a facility that does not offer comprehensive, integrated, multidisciplinary care. In a VA rehabilitation field survey published in December 2000, more than half of the respondents reported that the “rehabilitative care of stroke patients was incomplete, fragmented, and not well coordinated” at sites lacking a RBU (VA Stroke Medical Rehabilitation Questionnaire Results, 2000). In Department of Defense (DoD) medical treatment facilities, approximately 20 000 active-duty personnel and dependents were seen in 2002 for stroke and stroke-related diagnoses according to ICD-9 coding.3 Comprehensive treatment for stroke patients in DoD medical facilities is given primarily at medical centers. Smaller DoD community hospitals may have limited resources to see both inpatients and outpatients, relying more on the TRICARE network for ongoing stroke rehabilitation services. A growing body of evidence indicates that patients do better with a well-organized, multidisciplinary approach to post-acute rehabilitation after a stroke.4–6 The VA/DoD Stroke Rehabilitation Working Group only focused on the post–acute stroke rehabilitation care. Duncan and colleagues7 found that greater adherence to post-acute stroke rehabilitation guidelines was associated with improved patient outcomes and concluded “compliance …

877 citations


Journal ArticleDOI
TL;DR: A comprehensive review of the definitions and assessment tools on frailty in clinical practice and research was performed, combining evidence derived from a systematic review of literature along with an expert opinion of a European, Canadian and American Geriatric Advisory Panel (GAP).
Abstract: Frailty is a commonly used term indicating older persons at increased risk for adverse outcomes such as onset of disability, morbidity, institutionalisation or mortality or who experience a failure to integrate adequate responses in the face of stress. Although most physicians caring for older people recognize the importance of frailty, there is still a lack of both consensus definition and consensual clinical assessment tools. The aim of the present manuscript was to perform a comprehensive review of the definitions and assessment tools on frailty in clinical practice and research, combining evidence derived from a systematic review of literature along with an expert opinion of a European, Canadian and American Geriatric Advisory Panel (GAP). There was no consensus on a definition of frailty but there was agreement to consider frailty as a pre-disability stage. Being disability a consequence rather than the cause of frailty, frail older people do not necessary need to be disabled. The GAP considered that disability (as a consequence of frailty) should not be included in frailty definitions and assessment tools. Although no consensual assessment tool could be proposed, gait speed could represent the most suitable instrument to be implemented both in research and clinical evaluation of older people, as assessment of gait speed at usual pace is a quick, inexpensive and highly reliable measure of frailty.

740 citations


Cites methods from "Instrumental Activities of Daily Li..."

  • ...(32) Blaum and colleagues evaluated baseline data from the WHAS of a subpopulation of 599 women with a BMI greater than 18....

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  • ...(32) Purse, evaluated frailty following Fried and Rockwood’s diagnostic criteria, but added single item performances (gait speed, grip strength and repeated chair stands)....

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Journal ArticleDOI
TL;DR: A better understanding of these clinical changes and their underlying mechanisms may confirm the impression held by many geriatricians that increasing frailty is distinguishable from ageing and in consequence is potentially reversible.
Abstract: Frailty has long been considered synonymous with disability and comorbidity, to be highly prevalent in old age and to confer a high risk for falls, hospitalization and mortality. However, it is becoming recognized that frailty may be a distinct clinical syndrome with a biological basis. The frailty process appears to be a transitional state in the dynamic progression from robustness to functional decline. During this process, total physiological reserves decrease and become less likely to be sufficient for the maintenance and repair of the ageing body. Central to the clinical concept of frailty is that no single altered system alone defines it, but that multiple systems are involved. Clinical consensus regarding the phenotype which constitutes frailty, drawing upon the opinions of numerous authors, shows the characteristics to include wasting (loss of both muscle mass and strength and weight loss), loss of endurance, decreased balance and mobility, slowed performance, relative inactivity and, potentially, decreased cognitive function. Frailty is a distinct entity easily recognized by clinicians, with multiple manifestations and with no single symptom being sufficient or essential in its presentation. Manifestations include appearance (consistent or not with age), nutritional status (thin, weight loss), subjective health rating (health perception), performance (cognition, fatigue), sensory/physical impairments (vision, hearing, strength) and current care (medication, hospital). Although the early stages of the frailty process may be clinically silent, when depleted reserves reach an aggregate threshold leading to serious vulnerability, the syndrome may become detectable by looking at clinical, functional, behavioral and biological markers. Thus, a better understanding of these clinical changes and their underlying mechanisms, beginning in the pre-frail state, may confirm the impression held by many geriatricians that increasing frailty is distinguishable from ageing and in consequence is potentially reversible. We therefore provide an update of the physiopathology and clinical and biological characteristics of the frailty process and speculate on possible preventative approaches.

448 citations


References
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Journal ArticleDOI
TL;DR: Two scales first standardized on their own population are presented, one of which taps a level of functioning heretofore inadequately represented in attempts to assess everyday functional competence, and the other taps a schema of competence into which these behaviors fit.
Abstract: THE use of formal devices for assessing function is becoming standard in agencies serving the elderly. In the Gerontological Society's recent contract study on functional assessment (Howell, 1968), a large assortment of rating scales, checklists, and other techniques in use in applied settings was easily assembled. The present state of the trade seems to be one in which each investigator or practitioner feels an inner compusion to make his own scale and to cry that other existent scales cannot possibly fit his own setting. The authors join this company in presenting two scales first standardized on their own population (Lawton, 1969). They take some comfort, however, in the fact that one scale, the Physical Self-Maintenance Scale (PSMS), is largely a scale developed and used by other investigators (Lowenthal, 1964), which was adapted for use in our own institution. The second of the scales, the Instrumental Activities of Daily Living Scale (IADL), taps a level of functioning heretofore inadequately represented in attempts to assess everyday functional competence. Both of the scales have been tested further for their usefulness in a variety of types of institutions and other facilities serving community-resident older people. Before describing in detail the behavior measured by these two scales, we shall briefly describe the schema of competence into which these behaviors fit (Lawton, 1969). Human behavior is viewed as varying in the degree of complexity required for functioning in a variety of tasks. The lowest level is called life maintenance, followed by the successively more complex levels of func-

13,237 citations


Journal ArticleDOI
Eric Pfeiffer1
TL;DR: A 10‐item Short Portable Mental Status Questionnaire (SPMSQ), easily administered by any clinician in the office or in a hospital, has been designed, tested, standardized and validated.
Abstract: Clinicians whose practice includes elderly patients need a short, reliable instrument to detect the presence of intellectual impairment and to determine the degree. A 10-item Short Portable Mental Status Questionnaire (SPMSQ), easily administered by any clinician in the office or in a hospital, has been designed, tested, standardized and validated. The standardization and validation procedure included administering the test to 997 elderly persons residing in the community, to 141 elderly persons referred for psychiatric and other health and social problems to a multipurpose clinic, and to 102 elderly persons living in institutions such as nursing homes, homes for the aged, or state mental hospitals. It was found that educational level and race had to be taken into account in scoring individual performance. On the basis of the large community population, standards of performance were established for: 1) intact mental functioning, 2) borderline or mild organic impairment, 3) definite but moderate organic impairment, and 4) severe organic impairment. In the 141 clinic patients, the SPMSQ scores were correlated with the clinical diagnoses. There was a high level of agreement between the clinical diagnosis of organic brain syndrome and the SPMSQ scores that indicated moderate or severe organic impairment.

4,613 citations


Journal ArticleDOI
TL;DR: Among nondisabled older persons living in the community, objective measures of lower-extremity function were highly predictive of subsequent disability.
Abstract: Background Functional assessment is an important part of the evaluation of elderly persons. We conducted this study to determine whether objective measures of physical function can predict subsequent disability in older persons. Methods This prospective cohort study included men and women 71 years of age or older who were living in the community, who reported no disability in the activities of daily living, and who reported that they were able to walk one-half mile (0.8 km) and climb stairs without assistance. The subjects completed a short battery of physical-performance tests and participated in a follow-up interview four years later. The tests included an assessment of standing balance, a timed 8-ft (2.4-m) walk at a normal pace, and a timed test of five repetitions of rising from a chair and sitting down. Results Among the 1122 subjects who were not disabled at base line and who participated in the four-year follow-up, lower scores on the base-line performance tests were associated with a statisticall...

3,126 citations


Journal ArticleDOI
10 Jul 1987-Science
TL;DR: Research on the risks associated with usual aging and strategies to modify them should help elucidate how a transition from usual to successful aging can be facilitated.
Abstract: Research in aging has emphasized average age-related losses and neglected the substantial heterogeneity of older persons. The effects of the aging process itself have been exaggerated, and the modifying effects of diet, exercise, personal habits, and psychosocial factors underestimated. Within the category of normal aging, a distinction can be made between usual aging, in which extrinsic factors heighten the effects of aging alone, and successful aging, in which extrinsic factors play a neutral or positive role. Research on the risks associated with usual aging and strategies to modify them should help elucidate how a transition from usual to successful aging can be facilitated.

2,651 citations


Journal ArticleDOI
TL;DR: Among older people living in the community falls are a strong predictor of placement in a skilled-nursing facility; interventions that prevent falls and their sequelae may therefore delay or reduce the frequency of nursing home admissions.
Abstract: Background Falls warrant investigation as a risk factor for nursing home admission because falls are common and are associated with functional disability and because they may be preventable. Methods We conducted a prospective study of a probability sample of 1103 people over 71 years of age who were living in the community. Data on demographic and medical characteristics, use of health care, and cognitive, functional, psychological, and social functioning were obtained at base line and one year later during assessments in the participants' homes. The primary outcome studied was the number of days from the initial assessment to a first long-term admission to a skilled-nursing facility during three years of follow-up. Patients were assigned to four categories during follow-up: those who had no falls, those who had one fall without serious injury, those who had two or more falls without serious injury, and those who had at least one fall causing serious injury. Results A total of 133 participants (12.1 perce...

1,270 citations