There are separate, related articles Recurrent Falls, Prevention of Falls in the Elderly and Prescribing for the Older Patient.
The UK population is ageing. Disability in old age is frequent and lowers quality of life, and demands resources for 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 of disability in the elderly is a matter of 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". Limiting disability in older people is in line with this standard.
The World Health Organization has defined disability as the following:
"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.
The number of people aged 65 and over is estimated to increase by 65% in the next 25 years, with a doubling of the number of people aged >85 years. Managing older people's health effectively will be important.
The evidence for people aged <85 years tends to suggest that disability in the elderly is reducing, despite an increase in chronic diseases and conditions. For people aged >85 years, the trends regarding disability are less clear.
According to Canadian research, five types of chronic illness contribute largely to disability in people aged over 65 years:
- Foot problems
- Cognitive impairment
- Heart problems
Other common or important problems are:
- Hearing impairment.
- Chronic obstructive pulmonary disease (COPD) - probably more common in the elderly than is recognised.
- Falls and hip fracture.
In frail elderly people, a marked decline in physical and mental function can result from apparently small insults. This has been called the "domino" effect, with a small initial insult leading to a cascade of adverse events.
Frailty in the elderly may be due to a combination of predisposing factors (early childhood development and lifestyle), followed by contributing factors such as physical inactivity, chronic disease, and anorexia/malnutrition in later adulthood.
One review found that the main risk factors for functional disability in elderly people in the community were: lack of schooling, rented housing, chronic diseases, arthritis, diabetes, visual impairment, obesity, poor self-perceived health, cognitive impairment, depression, slow gait, sedentary lifestyle, tiredness while performing daily activities, and limited diversity in social relations.
The normal ageing process
Age is associated with a 1-2% decline in functional ability per year. Sedentary behaviour accelerates the loss of performance. Age-associated physiological changes include:
- Changes in body composition - reduction in muscle bulk and lean body mass, known as sarcopenia. Body fat may increase.
- Reduction in bone mass and strength with increased risk of fracture; osteoarthritic changes in joints.
- Reduction in blood volume, reduced tolerance of tachycardia; reduced ability to control blood pressure with postural change.
- Reduction in ventilatory capacity.
- Reduction in kidney function; 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).
- 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 elasticity of the eye's lens; high tone hearing impairment.
People aged 70 years and over often have have one or more chronic conditions. Comorbidities may contribute to disability - for example:
- Stroke can lead to weakness, co-ordination problems, locomotor difficulties and problems of communication and continence.
- Coronary heart disease may lead to heart failure, angina or myocardial infarction.
- Diabetes - complications that can contribute to disability in a variety of ways, eg the contribution of diabetic neuropathy to poor mobility may be underestimated.
- Alzheimer's disease is the most common neurodegenerative disease. By the age of 85 years, 30% of the population has Alzheimer's disease.
- Urinary problems can be disabling, particularly if causing incontinence.
- Depression is often the result of disability but it also makes disability worse. 10-15% of people aged over 65 years living at home are depressed.
- Visual loss is associated with an increased risk of falling.
- Hearing and visual impairment increase the risk of social isolation and resulting depression.
- 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.
- The damaged system.
- Other body systems.
- Medication - including polypharmacy.
- Function (such as ability to perform daily living activities):
- Activities of daily living (ADLs) - eating/dressing/toileting/mobility.
- Instrumental activities of daily living (IADLs) - dealing with medication/finances/housework/transportation.
- Environment - both the immediate environment (clothes and housing) and the locality (shops and social facilities).
- Formal and informal supports.
- Social and economic welfare.
Assessment by a specialist geriatrician and/or a multidisciplinary team specialising in elderly care can be useful.
A marked decline in function can be due to relatively small physiological insults, which may result in a frail older person being wrongly labelled as "unable to cope". Bear in mind that early comprehensive geriatric assessment and appropriate treatment may enable such patients to regain lost function.
Validated tools for assessment of disability or needs in elderly people include:
- Barthel's Index.
- Functional Independence Measure.
- Northwick Park Dependency Scale.
- Camberwell Assessment of Need in the Elderly.
- Various other tests, which have also been described.
Important aspects of management are:
- Treatment of unstable medical conditions and any treatable problems contributing to the disability.
- Reviewing drug treatment (including polypharmacy).
- Early mobilisation.
- Nutritional support.
- Comprehensive rehabilitation.
Who should be involved in management?
- A multidisciplinary approach can be helpful. This has been shown to be beneficial, eg following stroke and fractured neck of femur. Geriatric day hospitals have been shown to be beneficial in providing care to elderly people with functional decline, although a Cochrane review found they may not have any clear advantage over other forms of comprehensive elderly medical services.
- "Hospital at home" schemes have also been devised, although a Cochrane review found little evidence that they improved functional ability.
- "Case management" by community matrons is a recent development in the care of elderly patients and those with long-term conditions. A recent review of this strategy concluded that this provision is at an early stage of development, and needs to develop effective links with a range of local services. The financial viability of this service is not clear.
Aspects of management
Treat contributing causes
Do not assume that age-related disability is untreatable. Look for and treat contributing problems (where feasible), such as:
- Uncontrolled cardiac, respiratory or metabolic disease, eg heart failure, hypothyroidism.
- Reversible causes of hearing loss, eg wax.
- Potentially treatable neurological disease, eg tumours.
- 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. See the separate Prescribing for the Older Patient article that discusses this topic 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 years take vitamin D supplements.
- Age alone is not a contra-indication for surgery.
- Operations such as joint replacement, cataract surgery and surgery for prostatic hypertrophy are frequently performed on the elderly to reduce disability.
Provision of aids and appliances
- 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.
- 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.
- Hearing aids can greatly improve quality of life.
- Adapted safety devices may be needed (eg flashing light on telephone or smoke alarm).
A paper discussing chronic pain in elderly people suggests that persistent pain in elderly patients is not simply a chronologically older version of younger pain. They suggest that interventions such as a 'mindfulness-based stress reduction programme' can be helpful.
Appropriate exercise can be part of pain management in some conditions, eg osteoarthritis.
Social and environmental interventions
These may reduce the impact of the disability - for example:
- Financial support - eg access to benefits and grants.
- Social support - eg day centres, social activities and befriending.
- Housing support - appropriate accommodation can support independence and increase functional ability.
The National Service Framework states that there is strong evidence of benefit to older people from:
- Increasing physical activity.
- Improved diet and nutrition.
- Immunisation and management programmes for influenza.
Adapted exercise is beneficial for strength, mobility and balance, and may reduce the risk of falls. This applies even to frail older people. Indirectly, physical activity may also increase wellbeing, social activity and mental health.
Evidence on the role of exercise in preventing disability
In terms of preventing disability, some trials involving physical exercise interventions reported positive outcomes for disability. However, differences between the trials can make it difficult to review the evidence or to make precise recommendations.
A review disability from hip fracture suggested physical activity can protect against the risk of hip fracture among community-dwelling older adults. This may be via increased levels of vitamin D, or through the improvement of bone quality.
One editorial proposes 'assertive screening', using a single question to identify middle-aged and elderly people who are sedentary. These people could be invited to participate in lifestyle interventions including a prescription for exercise. It is suggested that a single question about a fall in the previous year is a method of identifying those who will benefit most.
How much exercise?
- The goal is to work towards 30 minutes of at least moderate-intensity physical activity on at least five days of the week.
- Two 15-minute periods of moderate activity daily may be a good way to start. If that is too much, take a 'little and often' approach, advising a gradual increase starting with just three minutes.
- The ideal is a combination of endurance exercises, strength exercises and stretching/balance/co-ordination exercises.
- It is never too late to start, and any activity is better than none.
- Adequate warm-up is important, and safe exercises/movement patterns should be chosen.
- Elderly people have relatively more body fat and less lean body mass, resulting in lower metabolic rates. Therefore, calorie needs are reduced, so the diet needs proportionately more protein, essential fats and micronutrients. Improving nutritional status (adequate calories and protein) can help to reduce sarcopenia and frailty in the elderly.
- Avoiding obesity is also beneficial.
- Aim to meet minimum nutritional requirements, provide adequate dietary fibre, and address specific disease risks such as cardiovascular disease, stroke, diabetes and osteoporosis.
- Vitamin D may help prevent muscle weakness, falls and fractures, but adequate doses must be used.
- Oral health and provision of dental treatment are important.
- Hospital nutrition - Age UK has campaigned for greater awareness of the problem of malnutrition in hospitalised elderly patients. Practical steps have been suggested, eg a 'red tray' system to indicate which patients need assistance at mealtimes.
- Folic acid ± vitamin B12 has been suggested as possibly benefiting cognitive function in elderly people. However, a Cochrane review concluded that there is no consistent evidence either way, and more research is needed.
Screening and case finding
Are health checks useful?
The value of health checks for older people is uncertain:
- Annual checks by a nurse visit have shown benefit in mortality, but not in UK studies.
- Case finding targets proactive care on individuals with a high level of need. Although interventions in this group are appreciated, a reduction in mortality or hospital admissions has not been shown.
- Screening programmes probably need to be intensive and sustained, if they are to deliver benefits.
- There is conflicting evidence regarding the benefits of preventive home visits to the elderly.
- One Canadian study looked at intervention by the emergency department, which identified high-risk elderly patients and referred them for community care. Better clinical outcomes were observed.
The British Geriatrics Society suggests that:
- A thorough assessment is needed for elderly people experiencing disability or a crisis.
- Otherwise, elderly people should be encouraged to follow healthy ageing advice.
NHS screening and prevention services for the elderly
The Department of Health recommends the following screening for elderly people:
- Annual influenza immunisation (and pneumococcal vaccine for those with chronic conditions such as COPD).
- Regular eye checks - free for people aged over 60; 2-yearly to age 60, annually from age 70.
- Hearing test - if a person's hearing is problematic or deteriorating.
- Bowel cancer screening - testing kits are sent every two years to people aged 60-69 who are registered with a GP. People aged >69 can request a kit every two years.
- Abdominal aortic aneurysm screening - is being made available to all men aged 65.
- Mammogram 3-yearly (over age 70 this must be requested by the woman).
- Cervical screening - women over age 65 are screened only if previous screening was abnormal or not done.
Healthy diet and lifestyle, including smoking cessation, should also be promoted.
Preventing falls and osteoporosis
Further reading & references
- Topinkova E; Aging, disability and frailty. Ann Nutr Metab. 2008;52 Suppl 1:6-11. Epub 2008 Mar 7.
- The Older Person in the Accident & Emergency Department, British Geriatrics Society - Best Practice Guide 3.2 (May 2008)
- National Service Framework for Older People, Dept of Health, 2001
- Disabilities: definition, World Health Organization
- Health and Social Care Bill Second Reading Briefing, Age UK, January 2011
- Christensen K, Doblhammer G, Rau R, et al; Ageing populations: the challenges ahead. Lancet. 2009 Oct 3;374(9696):1196-208.
- Griffith L, Raina P, Wu H, et al; Population attributable risk for functional disability associated with chronic Age Ageing. 2010 Nov;39(6):738-45. Epub 2010 Sep 1.
- Renwick DS, Connolly MJ; Prevalence and treatment of chronic airways obstruction in adults over the age of 45. Thorax. 1996 Feb;51(2):164-8.
- Marks R; Physical Activity and Hip Fracture Disability: A Review. Journal of Aging Research, 2011
- Heppenstall CP, Wilkinson TJ, Hanger HC, et al; Frailty: dominos or deliberation? N Z Med J. 2009 Jul 24;122(1299):42-53.
- Rodrigues MA, Facchini LA, Thume E, et al; Gender and incidence of functional disability in the elderly: a systematic Cad Saude Publica. 2009;25 Suppl 3:S464-76.
- Caird FI, Grimley Evans J. Medicine in old age. Concise Oxford Textbook of Medicine, Version 1. Chapter 19.1.
- Health Promotion and Preventive Care, British Geriatrics Society (BGS) Best Practice Guide 4.1 (reviewed 2005)
- Burton LA, Sumukadas D; Optimal management of sarcopenia. Clin Interv Aging. 2010 Sep 7;5:217-28.
- Resnick HE, Stansberry KB, Harris TB, et al; Diabetes, peripheral neuropathy, and old age disability. Muscle Nerve. 2002 Jan;25(1):43-50.
- Muché JA et al; Geriatric Rehabilitation, Medscape, Oct 2009
- Rehabilitation of Older People, British Geriatrics Society - Best Practice Guide 1.4 (revised 2009)
- Puxty J et al; Framework for Assessment of the Frail Elderly with Co-morbidities in Primary Care. Accessed May 2011
- Mahoney Fl, Barthel DW, Functional evaluation: the Barthel Index. Md State Med J. 1965 Feb;14:61-5.
- Siegert RJ, Turner-Stokes L; Psychometric evaluation of the Northwick Park Dependency Scale. J Rehabil Med. 2010 Nov;42(10):936-43.
- Camberwell Assessment of Need in the Elderly, University College London, accessed May 2011
- Pereira SR, Chiu W, Turner A, et al; How can we improve targeting of frail elderly patients to a geriatric BMC Geriatr. 2010 Nov 3;10:82.
- Tousignant M, Hebert R, Desrosiers J, et al; Economic evaluation of a geriatric day hospital: cost-benefit analysis based on functional autonomy changes. Age Ageing. 2003 Jan;32(1):53-9.
- Forster A, Young J, Lambley R, et al; Medical day hospital care for the elderly versus alternative forms of care. Cochrane Database Syst Rev. 2008 Oct 8;(4):CD001730.
- Shepperd S, Doll H, Angus RM, et al; Admission avoidance hospital at home. Cochrane Database Syst Rev. 2008 Oct 8;(4):CD007491.
- Challis D, Hughes J, Berzins K, et al; Implementation of case management in long-term conditions in England: survey and J Health Serv Res Policy. 2011 Apr;16 Suppl 1:8-13.
- Chapman L, Smith A, Williams V, et al; Community matrons: primary care professionals' views and experiences. J Adv Nurs. 2009 Aug;65(8):1617-25. Epub 2009 Apr 28.
- Karp JF, Shega JW, Morone NE, et al; Advances in understanding the mechanisms and management of persistent pain in Br J Anaesth. 2008 Jul;101(1):111-20. Epub 2008 May 16.
- Williams NH, Amoakwa E, Burton K, et al; The Hip and Knee Book: developing an active management booklet for hip and knee Br J Gen Pract. 2010 Feb;60(571):64-82.
- Bennell KL, Matthews B, Greig A, et al; Effects of an exercise and manual therapy program on physical impairments, BMC Musculoskelet Disord. 2010 Feb 17;11:36.
- Daniels R, van Rossum E, de Witte L, et al; Interventions to prevent disability in frail community-dwelling elderly: a BMC Health Serv Res. 2008 Dec 30;8:278.
- Forster A, Lambley R, Hardy J, et al; Rehabilitation for older people in long-term care. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD004294.
- Howe TE, Rochester L, Jackson A, et al; Exercise for improving balance in older people. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD004963.
- Campbell AJ; Assertive screening: health checks prior to exercise programmes in older people. Br J Sports Med. 2009 Jan;43(1):5. Epub 2008 Oct 16.
- Young A, Dinan S; Activity in later life. BMJ. 2005 Jan 22;330(7484):189-91.
- Rivlin RS; Keeping the young-elderly healthy: is it too late to improve our health through nutrition? Am J Clin Nutr. 2007 Nov;86(5):1572S-6S.
- Vanitallie TB; Frailty in the elderly: contributions of sarcopenia and visceral protein Metabolism. 2003 Oct;52(10 Suppl 2):22-6.
- Venning G; Recent developments in vitamin D deficiency and muscle weakness among elderly BMJ. 2005 Mar 5;330(7490):524-6.
- Still Hungry to Be Heard - the scandal of people in later life becoming malnourished in hospital, Age UK (2010)
- Malouf R, Grimley Evans J; Folic acid with or without vitamin B12 for the prevention and treatment of Cochrane Database Syst Rev. 2008 Oct 8;(4):CD004514.
- Health Checks and Case Finding - Best Practice Guide, British Geriatrics Society (May 2010)
- Kronborg C, Vass M, Lauridsen J, et al; Cost effectiveness of preventive home visits to the elderly: economic evaluation alongside randomized controlled study. Eur J Health Econ. 2006 Dec;7(4):238-46.
- Huss A, Stuck AE, Rubenstein LZ, et al; Multidimensional preventive home visit programs for community-dwelling older adults: a systematic review and meta-analysis of randomized controlled trials. J Gerontol A Biol Sci Med Sci. 2008 Mar;63(3):298-307.
- McCusker J, Jacobs P, Dendukuri N, et al; Cost-effectiveness of a brief two-stage emergency department intervention for high-risk elders: results of a quasi-randomized controlled trial. Ann Emerg Med. 2003 Jan;41(1):45-56.
- Keep on the road for longer. Health and social care services for people aged 50 and over, Dept of Health, Age Concern and Help the Aged, August 2009
|Original Author: Dr Michelle Wright||Current Version: Dr Naomi Hartree|
|Last Checked: 22/06/2011||Document ID: 2065 Version: 21||© EMIS|
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