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Disability in older people

Disability prevents normal function in life.

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

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

In addition there is cognitive impairment and impairment of vision and hearing.

Disability in old age is frequent and lowers the quality of life whilst straining limited resources for assistance, care and rehabilitation. Prevention is a matter of great humanitarian and economic concern.

Epidemiology
Prevalence

• Difficulties in basic activities like bathing, dressing, going to the toilet, continence, feeding and moving from chair to bed are reported by about 20% of those over 70 and 50% over 85. Common difficulties include problems with using the telephone, housekeeping and handling money.
• Inability to go out unaided affects 8% of those over 75 and 28% over 85.
• Between 75 and 84, 33% have problems hearing conversations and 20% have problems reading.
• In Wales, between the ages of 65 and 74, 45% of men and 42% of women are disabled. Over 75 the figures are 62% of men and 64% of women. Figures for England are slightly lower.
• On average women in Europe live 5 years longer than men but men have 1 year less of disability.

Risk Factors

• Disability is more common as age advances and is more frequent in lower socio-economic groups.
• Lifestyle is a much greater predictor of disability than genetics¹ that accounts for only about 30%.

Features Disability often has several components, especially in the elderly, and so a holistic approach is necessary. Be careful if denying the elderly procedures on the grounds of co-existing pathology: eg, performing a total hip replacement if exercise tolerance is hardly improved because angina supersedes (that degree of increased mobility may permit a pain-free independent lifestyle), or removing a cataract if there is significant macular degeneration (again small improvements in vision may reap wholly unexpected benefits).

Normal aging

• Osteoarthritis is an almost invariable companion to old age. It is not simply wear and tear but a disease of cartilage. Exercise is beneficial in prolonging the health of joints.
• Pain reduces activity and the erroneous belief that exercise of painful joints causes further damage, may lead to even less activity. This misconception must be dispelled. Inactivity leads to muscle wasting and power is lost. Loss of proprioception in muscles and joints follows, further predisposing to falls. Many old people who fear falls, limit activity still further. Poor strength, poor proprioception and poor coordination multiply as does the risk of falls and fractures.
• Osteoporosis is usually a latent condition. It is more common in women but still affects a significant number of men. Exercise improves bone mass and reduces the risk of falls.
• Atheroma starts in adolescence and progresses throughout life but most limitation of cardiovascular ability in the elderly is due to deconditioning rather than CHD. There is some inevitable decline of cardiac function with age but exercise will retard this² and protect against atheroma.
• Respiratory function also deteriorates with age but much faster in smokers. Exercise can reduce this.
• Dementia is a specific illness but some decline in mental ability is invariable with age. The principle of use it or loose it is as applicable to the mind as to the body and mental exercise is as important as physical conditioning.
• In most adults the optimum BMI is between 20 and 25 but in the elderly the ideal is a BMI of 25 to 30. Morbidity and mortality increase if weight is either above or below this. Weight should be kept under control, eating less as energy expenditure declines because obesity adds to all the problems of disability.
• Impairment of hearing, more marked in the upper frequencies, is invariable as age advances but it is accelerated by exposure to noise. Hearing aids should be introduced before deafness becomes advanced.
• Refractive problems are inevitable and there it little that can be done to prevent cataracts or macular degeneration.
• Sexual performance tends to decline with age in terms of both the will and the way but it would be wrong to assume that age alone is a barrier to sexual pleasure and problems of performance should be treated as sympathetically as in younger people. The Kinsey Report in 1953 found that 70% of men age 68 were sexually active. The figure today is probably significantly higher. Age is not a contraindication to sildenafil.

Disease People aged 70 and over usually have 2 or 3 chronic conditions, accounting for two thirds of NHS expenditure. By 75 years, 90% have some clinical diagnosis. Management of chronic diseases reduces disability.

• People fear stroke far more than myocardial infarction. The possible weakness, inco-ordination, locomotor difficulties and problems of communication and continence are justly feared. Stroke units and active rehabilitation are very important to reduce disability.
• CHD may cause heart failure or angina. Energetic management may be medical or surgical.
• It is likely than COPD is much more common in the elderly than is recognised³. 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 underestimated⁴.
• Alzheimer's disease is the commonest neurodegenerative disease. It is not simply part of the aging process. Dementia of any sort rises from 1% at 70 to 40% by age 85 to 90.
• The second commonest neurodegenerative condition is Parkinson's disease.
• Urinary problems can be disabling, especially incontinence. Faecal incontinence is even worse.
• Depression is often the result of disability but it also makes it worse. 10 to 15% of people over 65 living at home are depressed.

Management
Non-Drug A multidisciplinary approach is required.

• Make an accurate diagnosis of contributory conditions.
• Physiotherapy can improve many conditions. The patient should be given exercises to do at home too. This will effectively increase the hours per week and duration of treatment considerably.
• Tai Chi has been shown to be effective in preventing falls. The slow-movement martial art benefits cardiorespiratory function, improves strength and balance, and in turn can help self-confidence.
• Occupational therapy and the provision of aids can improve the quality of life.
• Use aids 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.

Drugs Medication can contribute to both the problem and the solution. No drug is without side-effects.

• CHD and congestive heart failure should be treated as aggressively as can be tolerated.
• Beware of postural hypotension, and diuretics may cause incontinence.
• If inhalers are required a MDI alone may not be handled well. Other devices are not just for children.
• Complications of NSAIDs are more common in the elderly.
• Drugs containing codeine or other opiates should be avoided if possible.
• The elderly are more susceptible to sedative effects of drugs.
• Depression often goes unnoticed but treatment⁵ is just as effective in old age.
• Acetylcholinesterase inhibitors (eg, aricept) are likely to gain a place in the treatment of all forms of dementia. Newer drugs such as N-methyl-D-aspartate (NMDAs, eg, memantine) blockers, and amyloid deposit inhibitors (eg, clioquinoline) are being introduced.
• Antioxidants, such as high dose vitamin C (perhaps in combination with vitamin E) are thought to have a role in prevention of dementia.

Try to avoid iatrogenic illness. The elderly are more likely to need multiple drugs for multiple diseases. They are more likely to get confused, even without cognitive impairment. Try to get them to understand what does what. Make sure that they are taking what you think they are taking. Do not ignore OTC preparations or "natural remedies".

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

Complications

• Both mental and physical disability predispose to admission to hospital, need for residential care and premature death.
• Cognitive impairment predisposes to death, especially from strokes⁶

Prevention Disability is not an invariable consequence of aging. Even in the disabled, interventions like exercise, stopping smoking and weight loss may be beneficial. Much evidence shows that physical activity may reduce depressive symptoms and prevent or delay functional limitations and disabilities in the elderly⁷. Long-term physical activity postpones disability and sustains independence, even for the chronically ill.

There are gaps and conflicting findings on the relative importance of various risk factors and the best ways of intervening. The benefits of comprehensive geriatric assessments and domiciliary visits have been examined in many studies. The results are inconclusive but promising. Evidence about the over 80s is very scanty but they are a rapidly growing group that is estimated to increase by 40% in Europe between 1995 and 2015. There is no evidence on the costs and benefits for various old-age disability preventive strategies.

References Used

1. Finkel D, Whitfield K, McGue M; Genetic and environmental influences on functional age: a twin study.;J Gerontol B Psychol Sci Soc Sci 1995 Mar;50(2):P104-13.[abstract]
2. Young A; Exercise physiology in geriatric practice.;Acta Med Scand Suppl 1986;711:227-32.[abstract]
3. 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.[abstract]
4. Resnick HE, Stansberry KB, Harris TB, et al; Diabetes, peripheral neuropathy, and old age disability.;Muscle Nerve 2002 Jan;25(1):43-50.[abstract]
5. Blazer DG; Depression in late life: review and commentary.;J Gerontol A Biol Sci Med Sci 2003 Mar;58(3):249-65.[abstract]
6. Gale CR, Martyn CN, Cooper C; Cognitive impairment and mortality in a cohort of elderly people.;BMJ 1996 Mar 9;312(7031):608-11.[abstract]
7. Wagner EH; Preventing decline in function. Evidence from randomized trials around the world.;West J Med 1997 Oct;167(4):295-8.[abstract]

Internet and Further Reading

• From the WHO office for Europe.
• Quality of life programme from EEC
• Disability in old age from Finland. Rather long but excellent content. (as PDF)
• Oxford Textbook of Geriatric Medicine, eds J Grimley Evans et al. 2nd ed OUP 2000. Many good chapters on physiological, medical and social aspects of aging.

Acknowledgements EMIS is grateful to the Mentor authoring team for writing this article. The final copy has passed peer review of the independent Mentor GP authoring team. ©EMIS 2004.

Last issued 30 Aug 2006