Recent Trends in Disability and Functioning Among Older Adults in the United States
01 Jan 2017-
TL;DR: In this paper, the authors evaluated survey quality according to 10 criteria, ranked the surveys as good, fair, or poor, and calculated for each outcome the average annual percent change.
Abstract: CONTEXT
Several well-publicized recent studies have suggested that disability among older Americans has declined in the last decade.
OBJECTIVES
To assess the quality, quantity, and consistency of recent evidence on US trends in the prevalence of self-rated old age disability and physical, cognitive, and sensory limitations during the late 1980s and 1990s and to evaluate the evidence on trends in disparities by major demographic groups.
DATA SOURCES
We searched MEDLINE and AGELINE for relevant articles published from January 1990 through May 2002 and reviewed reference lists in published articles.
STUDY SELECTION
From more than 800 titles reviewed, we selected 16 articles based on 8 unique repeat cross-sectional and cohort surveys of US prevalence trends in disability or functioning among persons generally aged 65 or 70 years or older.
DATA EXTRACTION
We evaluated survey quality according to 10 criteria, ranked the surveys as good, fair, or poor, and calculated for each outcome the average annual percent change.
DATA SYNTHESIS
Among the 8 surveys, 2 were rated as good, 4 as fair, 1 as poor, and 1 as mixed (fair or poor, depending on the outcome) for assessing trends. Analyses of surveys rated fair or good showed consistency of declines in any disability (-1.55% to -0.92% per year), instrumental activities of daily living disability (-2.74% to -0.40% per year), and functional limitations. Surveys provided limited evidence on cognition and conflicting evidence on self-reported ADL (changes ranged from -1.38% to 1.53% per year) and vision trends. Evidence on trends in disparities by age, sex, race, and education was limited and mixed, with no consensus yet emerging.
CONCLUSIONS
Several measures of old age disability and limitations have shown improvements in the last decade. Research into the causes of these improvements is needed to understand the implications for the future demand for medical care.
Citations
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TL;DR: Research suggests that ageing processes are modifiable and that people are living longer without severe disability, and this finding will be important for the chances to meet the challenges of ageing populations.
3,095 citations
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TL;DR: Adverse drug events are common and often preventable among older persons in the ambulatory clinical setting and prevention strategies should target the prescribing and monitoring stages of pharmaceutical care.
Abstract: ContextAdverse drug events, especially those that may be preventable, are among
the most serious concerns about medication use in older persons cared for
in the ambulatory clinical setting.ObjectiveTo assess the incidence and preventability of adverse drug events among
older persons in the ambulatory clinical setting.Design, Setting, and PatientsCohort study of all Medicare enrollees (30 397 person-years of
observation) cared for by a multispecialty group practice during a 12-month
study period (July 1, 1999, through June 30, 2000), in which possible drug-related
incidents occurring in the ambulatory clinical setting were detected using
multiple methods, including reports from health care providers; review of
hospital discharge summaries; review of emergency department notes; computer-generated
signals; automated free-text review of electronic clinic notes; and review
of administrative incident reports concerning medication errors.Main Outcome MeasuresNumber of adverse drug events, severity of the events (classified as
significant, serious, life-threatening, or fatal), and whether the events
were preventable.ResultsThere were 1523 identified adverse drug events, of which 27.6% (421)
were considered preventable. The overall rate of adverse drug events was 50.1
per 1000 person-years, with a rate of 13.8 preventable adverse drug events
per 1000 person-years. Of the adverse drug events, 578 (38.0%) were categorized
as serious, life-threatening, or fatal; 244 (42.2%) of these more severe events
were deemed preventable compared with 177 (18.7%) of the 945 significant adverse
drug events. Errors associated with preventable adverse drug events occurred
most often at the stages of prescribing (n = 246, 58.4%) and monitoring (n
= 256, 60.8%), and errors involving patient adherence (n = 89, 21.1%) also
were common. Cardiovascular medications (24.5%), followed by diuretics (22.1%),
nonopioid analgesics (15.4%), hypoglycemics (10.9%), and anticoagulants (10.2%)
were the most common medication categories associated with preventable adverse
drug events. Electrolyte/renal (26.6%), gastrointestinal tract (21.1%), hemorrhagic
(15.9%), metabolic/endocrine (13.8%), and neuropsychiatric (8.6%) events were
the most common types of preventable adverse drug events.ConclusionsAdverse drug events are common and often preventable among older persons
in the ambulatory clinical setting. More serious adverse drug events are more
likely to be preventable. Prevention strategies should target the prescribing
and monitoring stages of pharmaceutical care. Interventions focused on improving
patient adherence with prescribed regimens and monitoring of prescribed medications
also may be beneficial.
1,677 citations
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TL;DR: The transition began around 1800 with declining mortality in Europe and spread to all parts of the world and is projected to be completed by 2100 as mentioned in this paper, which has brought momentous changes, reshaping the economic and demographic life cycles of individuals and restructuring populations.
Abstract: Before the start of the demographic transition, life was short, births were many, growth was slow and the population was young. During the transition, e rst mortality and then fertility declined, causing population growth rates e rst to accelerate and then to slow again, moving toward low fertility, long life and an old population. The transition began around 1800 with declining mortality in Europe. It has now spread to all parts of the world and is projected to be completed by 2100. This global demographic transition has brought momentous changes, reshaping the economic and demographic life cycles of individuals and restructuring populations. Since 1800, global population size has already increased by a factor of six and by 2100 will have risen by a factor of ten. There will then be 50 times as many elderly, but only e ve times as many children; thus, the ratio of elders to children will have risen by a factor of ten. The length of life, which has already more than doubled, will have tripled, while births per woman will have dropped from six to two. In 1800, women spent about 70 percent of their adult years bearing and rearing young children, but that fraction has decreased in many parts of the world to only about 14 percent, due to lower fertility and longer life. 1 These changes are sketched in Table 1. These trends raise many questions and controversies. Did population grow so
840 citations
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TL;DR: Examination of reported trends in morbidity and mortality in older adults during the past two decades found some evidence for compression of morbidity, but with different methods, these measures are not directly comparable.
707 citations
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TL;DR: In most of the decedents, the course of disability in the last year of life did not follow a predictable pattern based on the condition leading to death, and a predominant trajectory was observed for subjects who died from advanced dementia.
Abstract: Methods We evaluated data on 383 decedents from a longitudinal study involving 754 community-dwelling older persons. None of the subjects had disability in essential activities of daily living at the beginning of the study, and the level of disability was ascertained during monthly interviews for more than 10 years. Information on the conditions leading to death was obtained from death certificates and comprehensive assessments that were completed at 18-month intervals after the baseline assessment. Results In the last year of life, five distinct trajectories were identified, from no disability to the most severe disability: 65 subjects had no disability (17.0%), 76 had catastrophic disability (19.8%), 67 had accelerated disability (17.5%), 91 had progressive disability (23.8%), and 84 had persistently severe disability (21.9%). The most common condition leading to death was frailty (in 107 subjects [27.9%]), followed by organ failure (in 82 subjects [21.4%]), cancer (in 74 subjects [19.3%]), other causes (in 57 subjects [14.9%]), advanced dementia (in 53 subjects [13.8%]), and sudden death (in 10 subjects [2.6%]). When the distribution of the disability trajectories was evaluated according to the conditions leading to death, a predominant trajectory was observed only for subjects who died from advanced dementia (67.9% of these subjects had a trajectory of persistently severe disability) and sudden death (50.0% of these subjects had no disability). For the four other conditions leading to death, no more than 34% of the subjects had any of the disability trajectories. The distribution of disability trajectories was particularly heterogeneous among the subjects with organ failure (from 12.2 to 32.9% of the subjects followed a specific trajectory) and frailty (from 14.0 to 27.1% of the subjects followed a specific trajectory). Conclusions In most of the decedents, the course of disability in the last year of life did not follow a predictable pattern based on the condition leading to death.
674 citations
References
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01 Jan 1981TL;DR: In this paper, the basic theory of Maximum Likelihood Estimation (MLE) is used to detect a difference between two different proportions of a given proportion in a single proportion.
Abstract: Preface.Preface to the Second Edition.Preface to the First Edition.1. An Introduction to Applied Probability.2. Statistical Inference for a Single Proportion.3. Assessing Significance in a Fourfold Table.4. Determining Sample Sizes Needed to Detect a Difference Between Two Proportions.5. How to Randomize.6. Comparative Studies: Cross-Sectional, Naturalistic, or Multinomial Sampling.7. Comparative Studies: Prospective and Retrospective Sampling.8. Randomized Controlled Trials.9. The Comparison of Proportions from Several Independent Samples.10. Combining Evidence from Fourfold Tables.11. Logistic Regression.12. Poisson Regression.13. Analysis of Data from Matched Samples.14. Regression Models for Matched Samples.15. Analysis of Correlated Binary Data.16. Missing Data.17. Misclassification Errors: Effects, Control, and Adjustment.18. The Measurement of Interrater Agreement.19. The Standardization of Rates.Appendix A. Numerical Tables.Appendix B. The Basic Theory of Maximum Likelihood Estimation.Appendix C. Answers to Selected Problems.Author Index.Subject Index.
16,435 citations
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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-
14,832 citations
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TL;DR: The Index of ADL as discussed by the authors was developed to study results of treatment and prognosis in the elderly and chronically ill. Grades of the Index summarize over-all performance in bathing, dressing, going to toilet, transferring, continence, and feeding.
Abstract: The Index of ADL was developed to study results of treatment and prognosis in the elderly and chronically ill. Grades of the Index summarize over-all performance in bathing, dressing, going to toilet, transferring, continence, and feeding. More than 2,000 evaluations of 1,001 individuals demonstrated use of the Index as a survey instrument, as an objective guide to the course of chronic illness, as a tool for studying the aging process, and as an aid in rehabilitation teaching. Of theoretical interest is the observation that the order of recovery of Index functions in disabled patients is remarkably similar to the order of development of primary functions in children. This parallelism, and similarity to the behavior of primitive peoples, suggests that the Index is based on primary biological and psychosocial function, reflecting the adequacy of organized neurological and locomotor response.
10,971 citations
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10,442 citations
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TL;DR: Treatment with oral conjugated equine estrogen plus medroxyprogesterone acetate did not reduce the overall rate of CHD events in postmenopausal women with established coronary disease and the treatment did increase the rate of thromboembolic events and gallbladder disease.
Abstract: Context.—Observational studies have found lower rates of coronary heart disease
(CHD) in postmenopausal women who take estrogen than in women who do not,
but this potential benefit has not been confirmed in clinical trials.Objective.—To determine if estrogen plus progestin therapy alters the risk for
CHD events in postmenopausal women with established coronary disease.Design.—Randomized, blinded, placebo-controlled secondary prevention trial.Setting.—Outpatient and community settings at 20 US clinical centers.Participants.—A total of 2763 women with coronary disease, younger than 80 years,
and postmenopausal with an intact uterus. Mean age was 66.7 years.Intervention.—Either 0.625 mg of conjugated equine estrogens plus 2.5 mg of medroxyprogesterone
acetate in 1 tablet daily (n=1380) or a placebo of identical appearance (n=1383).
Follow-up averaged 4.1 years; 82% of those assigned to hormone treatment were
taking it at the end of 1 year, and 75% at the end of 3 years.Main Outcome Measures.—The primary outcome was the occurrence of nonfatal myocardial infarction
(MI) or CHD death. Secondary cardiovascular outcomes included coronary revascularization,
unstable angina, congestive heart failure, resuscitated cardiac arrest, stroke
or transient ischemic attack, and peripheral arterial disease. All-cause mortality
was also considered.Results.—Overall, there were no significant differences between groups in the
primary outcome or in any of the secondary cardiovascular outcomes: 172 women
in the hormone group and 176 women in the placebo group had MI or CHD death
(relative hazard [RH], 0.99; 95% confidence interval [CI], 0.80-1.22). The
lack of an overall effect occurred despite a net 11% lower low-density lipoprotein
cholesterol level and 10% higher high-density lipoprotein cholesterol level
in the hormone group compared with the placebo group (each P<.001). Within the overall null effect, there was a statistically
significant time trend, with more CHD events in the hormone group than in
the placebo group in year 1 and fewer in years 4 and 5. More women in the
hormone group than in the placebo group experienced venous thromboembolic
events (34 vs 12; RH, 2.89; 95% CI, 1.50-5.58) and gallbladder disease (84
vs 62; RH, 1.38; 95% CI, 1.00-1.92). There were no significant differences
in several other end points for which power was limited, including fracture,
cancer, and total mortality (131 vs 123 deaths; RH, 1.08; 95% CI, 0.84-1.38).Conclusions.—During an average follow-up of 4.1 years, treatment with oral conjugated
equine estrogen plus medroxyprogesterone acetate did not reduce the overall
rate of CHD events in postmenopausal women with established coronary disease.
The treatment did increase the rate of thromboembolic events and gallbladder
disease. Based on the finding of no overall cardiovascular benefit and a pattern
of early increase in risk of CHD events, we do not recommend starting this
treatment for the purpose of secondary prevention of CHD. However, given the
favorable pattern of CHD events after several years of therapy, it could be
appropriate for women already receiving this treatment to continue.
5,991 citations