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Difficulty and Dependence: Two Components of the Disability Continuum among Community-Living Older Persons

Thomas M. Gill, MD; Julie T. Robison, PhD; and Mary E. Tinetti, MD
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From Yale University School of Medicine, New Haven, Connecticut. Acknowledgments: The authors thank Christianna Williams for assembling the hospitalization database, Janette Nabors for technical assistance, and Dr. Peter Peduzzi for statistical advice and expertise. Grant Support: In part by the Claude D. Pepper Older Americans Independence Center (P60 AG-10469) and grant R01 AG-07449 from the National Institute on Aging. The study was conducted while Dr. Gill was a Pfizer/AGS Postdoctoral Fellow. Dr. Gill is currently a Robert Wood Johnson Foundation Generalist Physician Faculty Scholar and a Paul Beeson Physician Faculty Scholar in Aging Research. Dr. Robison was supported by a Research Training Award in the Epidemiology of Aging from the National Institute on Aging (5T32-AG00153). Requests for Reprints: Thomas M. Gill, MD, Yale University School of Medicine, Program in Geriatrics, 20 York Street, Room TMP-17B, New Haven, CT 06504. Current Author Addresses: Drs. Gill and Tinetti: Yale University School of Medicine, Room 17B-TMP, PO Box 208025, New Haven, CT 06520-8025.


Copyright ©2004 by the American College of Physicians


Ann Intern Med. 1998;128(2):96-101. doi:10.7326/0003-4819-128-2-199801150-00004
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Background: Although most epidemiologic studies have defined disability in basic activities of daily living (BADLs) as dependence, some investigators have argued that BADL disability should be defined as degree of difficulty.

Objective: To determine whether the responses to questions about difficulty and dependence provide complementary information that together can depict the continuum of disability more fully than the response to either question alone.

Setting: General community.

Participants: 1065 persons 72 years of age and older.

Measurements: On the basis of self-reported information collected at baseline, participants were categorized into three BADL groups: independent without difficulty, independent with difficulty, and dependent. Additional baseline information was collected on several measures of higher-level function and physical performance. Follow-up information was collected on regular home care visits and BADL function at 1 and 3 years and on hospitalizations, admissions to skilled-nursing facilities, and deaths over a 4-year period.

Results: In a cross-sectional analysis, the proportion of participants with poor higher-level function and physical performance increased substantially across the three BADL groups. In a longitudinal analysis, the rates of hospitalization and regular home care visits for the independent without difficulty group, the independent with difficulty group, and the dependent group were 46%, 57%, and 72% (P < 0.001) and 17%, 30%, and 49% (P < 0.001), respectively; survival curves for admission to a skilled-nursing facility and death differed significantly for each pair-wise comparison. Among persons who were BADL independent, those with difficulty were significantly more likely to develop BADL dependence over a 3-year period than those without difficulty (31% compared with 18%; P < 0.001).

Conclusions: In the assessment of BADL function in older persons, questions about difficulty and dependence provide complementary information that together can depict the continuum of disability more fully than either question alone.

Topics

disability ; elderly

Figures

Grahic Jump Location
Figure 1.
Cumulative probability of admission to a skilled-nursing facility for the three basic activity of daily living groups.PP

The data were calculated by using the product-limit method of Kaplan and Meier. Data on participants who died without an admission to a skilled-nursing facility were censored at the time of death. < 0.001 by log-rank test for comparisons between curves A and B and curves A and C; = 0.017 by log-rank test for comparison between curves B and C.

Grahic Jump Location
Grahic Jump Location
Figure 2.
Mortality curves for the three basic activity of daily living groups.PPP

The data were calculated by using the product-limit method of Kaplan and Meier. = 0.034 by log-rank test for comparison between curves A and B; < 0.001 by log-rank test for comparison between curves A and C; < 0.003 by log-rank test for comparison between curves B and C.

Grahic Jump Location

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