Disability in Older People

There are separate, related articles on:

• Recurrent Falls
• Prevention of Falls in the Elderly
• Prescribing for the Older Patient

Our population is ageing. Disability in old age is frequent and lowers quality of life whilst straining limited resources for assistance, care and rehabilitation. Both mental and physical disability predispose to admission to hospital, need for residential care and premature death. Helping to combat disability in the elderly can improve quality of life. Prevention is a matter of great humanitarian and economic concern.

Standard Eight of the National Service Framework for Older People is concerned about “the promotion of health and active life in older age”. The aim of this standard is to extend the healthy life expectancy of older people. Limiting disability in older people would be in line with this standard.¹

The World Health Organisation has defined disability as the following:²

"Disability is an umbrella term, covering impairments, activity limitations, and participation restrictions. An impairment is a problem in body function or structure; an activity limitation is a difficulty encountered by an individual in executing a task or action; while a participation restriction is a problem experienced by an individual in involvement in life situations. Thus disability is a complex phenomenon, reflecting an interaction between features of a person’s body and features of the society in which he or she lives."

Activities of daily living (ADLs) include personal-care activities such as eating, bathing, dressing, and using the toilet.

Instrumental activities of daily living (IADLs) include household chores, shopping, managing medication, climbing stairs, public transport, finances, and walking. They can be affected by cognitive impairment.

• Age is associated with a 1-2% decline in functional ability per year and sedentary behaviour accelerates the loss of performance.³
• Difficulties in basic activities like bathing, dressing, going to the toilet, continence, feeding and moving from chair to bed are reported by a significant number of those over 70 and even more of those over 85. Common difficulties also include problems with using the telephone, housekeeping and handling money.
• Inability to go out unaided affects a significant number of over 75 year olds.
• Hearing and reading difficulty is also more common over the age of 75.
• Social isolation and loneliness are likely to become an increasingly widespread problem among older people in Britain as a result of people living longer, changing family structures, and greater mobility in the working population.
• By the year 2025, 20% of the population in industrial countries will be aged 65 and over and more than 60% of women over 75 will be living alone.³

The normal ageing process may mean that elderly people are more at risk of disability. Some of the age-associated physiological changes include the following:

• Changes in body composition - reduction in muscle bulk (resulting in loss of strength and power) and lean body mass (resulting in reduced oxygen consumption), increase in body fat
• Reduction in blood volume
• Increase in fibrous tissue in the myocardium and heart valves
• Decreased elasticity in the aorta which can lead to a rise in blood pressure
• Less tolerance of tachycardia
• Reduction in ventilatory capacity
• Reduction in glomerular filtration rate and changes in tubular function so that urea and creatinine concentrations rise
• Impaired thirst mechanisms which increase susceptibility to dehydration
• Reduced sensitivity to vitamin D and subsequent reduction in calcium absorption
• Reduced motility of the large bowel
• Reduced hepatic mass and blood flow (which may affect hepatic metabolism of drugs)
• Reduction in bone mass and strength with increased risk of fracture
• Osteoarthritic changes in joints
• Nervous system changes including reduction in cortical function and reduced motor and sensory peripheral nerve function
• Changes in autonomic function including control of heart rate and temperature regulation (failure of normal response mechanisms to hot and cold)
• Reduced ability to control blood pressure in response to postural change
• Reduced elasticity of the lens
• High tone hearing impairment

People aged 70 and over usually have 2 or 3 chronic conditions. By 75 years, 90% have some clinical diagnosis. Co-morbidities may contribute to disability. Effective management of chronic diseases may reduce disability.

• Stroke can lead to weakness, coordination problems, locomotor difficulties and problems of communication and continence.
• Coronary heart disease may lead to heart failure, angina or myocardial infarction.
• It is likely than COPD is much more common in the elderly than is recognised.⁵ It is not too late to stop smoking.
• Diabetes causes numerous complications that can contribute to disability in a variety of ways. It is likely that the contribution of diabetic neuropathy to poor mobility is underestimated.⁶
• Alzheimer's disease is the commonest neurodegenerative disease. It is not simply part of the ageing process. By the age of 85 years, 30% of the population has Alzheimer's disease.⁷
• Urinary problems can be disabling, especially incontinence. Faecal incontinence may also occur.
• Depression is often the result of disability but it also makes disability worse. 10 to 15% of people over 65 living at home are depressed.

• This can affect understanding of commands or questions and can affect ability of the elderly person to express themselves.
• 25-50% of people >65 years have significant hearing loss; 50% of people >75 years have significant hearing loss.⁷
• Exclude potentially reversible causes such as wax, cholesteatomas, acoustic neuromas.
• Presbycusis is age-related decline in hearing; a conductive loss usually affecting ability to hear high-frequency sound and complex sounds.⁷
• There may be related withdrawal, depression, anxiety and safety issues (ability to hear fire alarms, door bells, telephones).
• Hearing screening, assessment and treatment of hearing loss is essential.
• Hearing aids can greatly improve quality of life.
• Adapted safety devices may be needed (e.g. flashing light on telephone).

• Presbyopia is the gradual loss of ability to focus on near objects with increasing age.⁷
• 92% of people have presbyopia by 75 years.⁷
• 95% of people >65 years have cataracts.⁷
• Glaucoma, age-related macular degeneration and diabetic eye disease are also more common in elderly patients.
• Visual loss is associated with an increased risk of falling.
• There may be social isolation, inability to perform activities of daily living and depression.
• Visual assessment should be carried out.
• Glasses, low vision aids such as magnifying glasses, large-print materials, talking clocks and watches, telephones with large numbers, audio-books, safety measures such as raised-dot dials on kitchen equipment may all be helpful.⁷

One third of people over 65 in the community fall each year.^8,9 This results in 200,000 admissions to hospital.^9,10 There are various age-related physiological changes which make falls more likely in the elderly. These include:⁷

• Reduced muscle mass and strength
• Increased reaction times
• Orthostatic hypotension
• Visual impairment
• Altered proprioception
• Cognitive impairment
• Impaired mobility

Falls are associated with injury, pain and loss of function. The prevalence of osteoporosis in the elderly population means that falls are more likely to result in fractures. There are separate articles that discuss falls in older people in more detail: Recurrent Falls (click here), Prevention of Falls in the Elderly (and here). There is also a separate article entitled Osteoporosis.

• Disability often has several components, especially in the elderly, and so an holistic, multidisciplinary approach is necessary.
• Make an accurate diagnosis of contributing conditions and co-morbidities .
• Physiotherapy can improve many conditions.
• Tai Chi has been shown to be effective in preventing falls. The slow-movement martial art benefits cardiorespiratory function, improves strength and balance, and can also help self-confidence.
• Occupational therapy and the provision of aids can improve the quality of life. Home adjustments such as grip rails, stair lifts and removal of dangers such as loose carpets or inappropriate footwear can be helpful.
• Aids should be used to make the most of impaired vision or hearing.
• Even at a late stage, prophylactic activities like exercise, weight control and cessation of smoking may still be beneficial.
• Rehabilitation to reduce functional deficit in someone with a chronic disease should also be key in reducing disability.¹¹
• Geriatric day hospitals have also been shown to be beneficial in providing care to elderly people with functional decline.¹²

Drug treatment

• Medication can contribute to both the problem of disability and the solution.
• Polypharmacy and increased susceptibility to drug side effects are some of the issues surrounding medication in older people. There is a separate article that discusses Prescribing for the Older Patient in detail.
• Vitamin D deficiency should be recognised and treated in the elderly. The Department of Health has recommended that people over the age of 65 take vitamin D supplements.

Surgical treatment

• Age alone is not a contraindication for surgery.
• Operations such as joint replacement, cataract surgery and surgery for prostatic hypertrophy are frequently performed on the elderly to reduce disability.

• Disability is not an inevitable consequence of aging. Even in the disabled, interventions like exercise, smoking cessation and weight loss may be beneficial.
• There are gaps and conflicting findings on the relative importance of various risk factors and the best ways of intervening.
• One study looked at preventive home visits to the elderly to maintain their health and autonomy and prevent disability. The results were inconclusive and it was suggested that further research is needed.¹³ Another systematic review showed that preventive home visits have the potential to reduce disability burden among older adults when based on multidimensional assessment with clinical examination.¹⁴
• Another study looked at intervention by the emergency department, identifying high-risk elderly patients, screening for unresolved problems and referring for community care. Better clinical outcomes were observed.¹⁵
• Occupational therapy input has also been shown to be effective in improving quality of life for independently living elderly people.¹⁶
• Prevention should also incorporate opportunistic screening for, and appropriate management of, chronic disease.

The role of physical activity¹⁷

Much evidence shows that physical activity may reduce depressive symptoms and prevent or delay functional limitations and disabilities in the elderly.¹⁸ Long-term physical activity postpones disability and sustains independence, even for the chronically ill.

• Regular physical activity can help to prevent some important conditions in the elderly that may lead to disability including:
  • Osteoporosis
  • Type 2 diabetes
  • Hypertension
  • Cardiovascular disease
  • Anxiety and depression
  • Some cancers
• It also helps to preserve function by improving strength, power, endurance, flexibility and balance.
• It can reduce the risk of falls and therefore subsequent fractures.
• It helps to prevent immobility which can lead to faecal impaction, deep vein thrombosis and gravitational oedema.
• By encouraging socialisation, it can help to reduce isolation and subsequent loneliness and/or depression.
• Exercise may help arthritic pain.
• It can help poor sleep.
• It may improve functional ability in those with asthma, chronic obstructive pulmonary disease, heart failure, angina and intermittent claudication.

How much exercise?¹⁷

• The goal is to work towards 30 minutes of at least moderate intensity physical activity on at least 5 days of the week.
• Endurance exercises should be built in for 20 minutes 3 times a week.
• Strength exercises should be built in for 20 minutes twice a week.
• There should be daily stretching, balance and coordination exercises.
• Adequate warm-up should be built in for each session.

The role of nutrition¹⁹

• Elderly people have relatively more body fat and less lean body mass (muscle and bone). This means that their metabolic rates are lower (muscle tissue has a higher metabolic rate than fat tissue). Therefore calorie intake needs to be reduced in the elderly and energy consumption through exercise needs to be increased. However, this means that the diet needs to be highly nutritious, with proportionately more protein, essential fats and micronutrients, so that adequate amounts of these can be obtained despite the reduced overall calorie need.
• Vitamin D supplements have been shown to slow the rate of bone loss and reduce the incidence of non-vertebral fractures.
• Nutritional and lifestyle guidelines for cancer prevention can reduce risk by one-third.
• Improving lipid concentrations in adults over the age of 65 with coronary artery disease can decrease the risk of future cardiac events by up to 45%.
• One study showed that amongst individuals aged 70-90, adherence to a Mediterranean diet and healthy lifestyle is associated with a more than 59% lower rate of all-causes and cause specific mortality.²⁰
• Raised homocysteine levels have been linked to the occurrence of diseases in older age including Alzheimer’s disease and cardiovascular and cerebro-vascular disease. There is some evidence that homocysteine lowering agents such as folic acid and to a lesser extent B12 supplements may have a beneficial and controlling effect on the development of these pathologies.²¹