B-cell intrinsic and extrinsic signals that regulate central tolerance of mouse and human B cells.

The random recombination of immunoglobulin V(D)J gene segments produces unique IgM antibodies that serve as the antigen receptor for each developing B cell. Hence, the newly formed B cell repertoire is comprised of a variety of specificities that display a range of reactivity with self-antigens. Newly generated IgM+ immature B cells that are non-autoreactive or that bind self-antigen with low avidity are licensed to leave the bone marrow with their intact antigen receptor and to travel via the blood to the peripheral lymphoid tissue for further selection and maturation. In contrast, clones with medium to high avidity for self-antigen remain within the marrow and undergo central tolerance, a process that revises their antigen receptor or eliminates the autoreactive B cell altogether. Thus, central B cell tolerance is critical for reducing the autoreactive capacity and avidity for self-antigen of our circulating B cell repertoire. Bone marrow cultures and mouse models have been instrumental for understanding the mechanisms that regulate the selection of bone marrow B cells. Here, we review recent studies that have shed new light on the contribution of the ERK, PI3K, and CXCR4 signaling pathways in the selection of mouse and human immature B cells that either bind or do not bind self-antigen.

Palliative Care Early in the Care Continuum among Patients with Serious Respiratory Illness: An Official ATS/AAHPM/HPNA/SWHPN Policy Statement.

Background: Patients with serious respiratory illness and their caregivers suffer considerable burdens, and palliative care is a fundamental right for anyone who needs it. However, the overwhelming majority of patients do not receive timely palliative care before the end of life, despite robust evidence for improved outcomes. Goals: This policy statement by the American Thoracic Society (ATS) and partnering societies advocates for improved integration of high-quality palliative care early in the care continuum for patients with serious respiratory illness and their caregivers and provides clinicians and policymakers with a framework to accomplish this. Methods: An international and interprofessional expert committee, including patients and caregivers, achieved consensus across a diverse working group representing pulmonary-critical care, palliative care, bioethics, health law and policy, geriatrics, nursing, physiotherapy, social work, pharmacy, patient advocacy, psychology, and sociology. Results: The committee developed fundamental values, principles, and policy recommendations for integrating palliative care in serious respiratory illness care across seven domains: 1) delivery models, 2) comprehensive symptom assessment and management, 3) advance care planning and goals of care discussions, 4) caregiver support, 5) health disparities, 6) mass casualty events and emergency preparedness, and 7) research priorities. The recommendations encourage timely integration of palliative care, promote innovative primary and secondary or specialist palliative care delivery models, and advocate for research and policy initiatives to improve the availability and quality of palliative care for patients and their caregivers. Conclusions: This multisociety policy statement establishes a framework for early palliative care in serious respiratory illness and provides guidance for pulmonary-critical care clinicians and policymakers for its proactive integration.

Multiple Dimensions and Correlates of Fatigue in Individuals on Hemodialysis.

This study examined the severity, pattern, and correlates of fatigue among adults undergoing hemodialysis. Measures included the Piper Fatigue Scale (PFS-12), Patient-Reported Outcomes Measurement Information System (PROMIS) - Fatigue, Charlson Comorbidity Index, and Six-Minute Walk Test (6MWT). Patients were excluded if mobility or cardiovascular issues prevented conducting the 6MWT. Participants were 86 cognitively intact adults (M = 61.7 years, SD = 13.81), predominantly male (58.1%), and African American (48.8%), with 80% reporting fatigue in the week prior to hemodialysis. Significant increases were noted in sensory and cognitive fatigue from pre- to post-dialysis, while the 6MWT distance decreased significantly pre- to post-dialysis. Factors significantly associated with pre-dialysis fatigue included low hemoglobin, younger age, and living with someone else, while comorbidities and dialysis inadequacy were trending to significant associations with fatigue.

Fatigue in Patients with Chronic Kidney Disease: Evidence and Measures.

As many as 70% to 97% of individuals with chronic kidney disease (CKD) report fatigue. Fatigue is one of the common, troubling symptoms that affects one's quality of life. This narrative review summarizes the evidence and gaps about the epidemiology, causative factors, and assessment of fatigue in individuals with CKD. Most studies are focused on the hemodialysis population, with very few focused on the peritoneal dialysis and transplant populations in which fatigue is also prevalent. Understanding fatigue and its correlates can help in assessing fatigue and in implementing interventions to alleviate fatigue.

Intensity cut-points for the Respiratory Distress Observation Scale.

BACKGROUND: The Respiratory Distress Observation Scale(©) is an innovative solution to assessment when a dyspnea report cannot be elicited. The Respiratory Distress Observation Scale has acceptable reliability and validity psychometrics. AIM: To identify distress-intensity cut-points of the Respiratory Distress Observation Scale. DESIGN: Receiver operating characteristic curve analysis was conducted with inpatients stratified by four levels of respiratory distress-none, mild, moderate, or severe. Patients provided three self-report measures of dyspnea: dichotomous (yes/no); a ranking of none, mild, moderate, or severe; and a numerical rating scale. Respiratory distress was assessed using the Respiratory Distress Observation Scale instrument. SETTING/PARTICIPANTS: Participants were 136 adult inpatients, mean age 61.8 years (standard deviation = 13.18 years), 89.7% African American, and 56.6% female, who were recruited from an urban, tertiary care hospital in the Midwest of the United States. RESULTS: In all, 47% (n = 64) self-reported dyspnea (yes/no). Ranking was distributed as follows: none = 36, mild = 35, moderate = 40, and severe = 25. Numerical rating scale scores ranged from 0 to 10, mean = 4.99 (standard deviation = 2.9). Respiratory Distress Observation Scale scores ranged from 0 to 7, median (interquartile range) = 2 (1-3). Receiver operating characteristic curve analysis-determined Respiratory Distress Observation Scale score of 0-2 suggests little or no respiratory distress; score ≥3 signified moderate to severe distress. CONCLUSION: A Respiratory Distress Observation Scale score ≥3 signifies a patient's need for palliation of respiratory distress. An end-point for identifying responsiveness to treatment, in other words, respiratory comfort, is Respiratory Distress Observation Scale <3. Because patients with imminent respiratory failure, as typified by dying patients, were not represented yielding lower than expected Respiratory Distress Observation Scale scores, further substantiation is needed to determine moderate or severe cut-points.

Effectiveness of an Algorithmic Approach to Ventilator Withdrawal at the End of Life: A Stepped Wedge Cluster Randomized Trial.

Background: The transition to spontaneous breathing puts patients who are undergoing ventilator withdrawal at high risk for developing respiratory distress. A patient-centered algorithmic approach could standardize this process and meet unique patient needs because a single approach (weaning vs. one-step extubation) does not capture the needs of a heterogenous population undergoing this palliative procedure. Objectives: (1) Demonstrate that the algorithmic approach can be effective to ensure greater patient respiratory comfort compared to usual care; (2) determine differences in opioid or benzodiazepine use; (3) predict factors associated with duration of survival. Design/Settings/Measures: A stepped-wedge cluster randomized design at five sites was used. Sites crossed over to the algorithm in random order after usual care data were obtained. Patient comfort was measured with the Respiratory Distress Observation Scale© (RDOS) at baseline, at ventilator off, and every 15-minutes for an hour. Parenteral morphine and lorazepam equivalents from the onset of the process until patient death were calculated. Results: Usual care data n = 120, algorithm data n = 48. Gender and race were evenly distributed. All patients in the usual care arm underwent a one-step ventilator cessation; 58% of patients in the algorithm arm were weaned over an average of 18 ± 27 minutes as prescribed in the algorithm. Patients had significantly less respiratory distress in the intervention arm (F = 10.41, p = 0.0013, effective size [es] = 0.49). More opioids (t = -2.30, p = 0.023) and benzodiazepines (t = -2.08, p = 0.040) were given in the control arm. Conclusions: The algorithm was effective in ensuring patient respiratory comfort. Surprisingly, more medication was given in the usual care arm; however, less may be needed when distress is objectively measured (RDOS), and treatment is initiated as soon as distress develops as in the algorithm. Clinical Trial Registration number: NCT03121391.

Process of Withdrawal of Mechanical Ventilation at End of Life in the ICU: Clinician Perceptions.

BACKGROUND: Nearly one-quarter of all Americans die in the ICU. Many of their deaths are anticipated and occur following the withdrawal of mechanical ventilation (WMV). However, there are few data on which to base best practices for interdisciplinary ICU teams to conduct WMV. RESEARCH QUESTION: What are the perceptions of current WMV practices among ICU clinicians, and what are their opinions of processes that might improve the practice of WMV at end of life in the ICU? STUDY DESIGN AND METHODS: This prospective two-center observational study conducted in Boston, Massachusetts, the Observational Study of the Withdrawal of Mechanical Ventilation (OBSERVE-WMV) was designed to better understand the perspectives of clinicians and experience of patients undergoing WMV. This report focuses on analyses of qualitative data obtained from in-person surveys administered to the ICU clinicians (nurses, respiratory therapists, and physicians) caring for these patients. Surveys assessed a broad range of clinician perspectives on planning, as well as the key processes required for WMV. This analysis used independent open, inductive coding of responses to open-ended questions. Initial codes were reconciled iteratively and then organized and interpreted using a thematic analysis approach. Opinions were assessed on how WMV could be improved for individual patients and the ICU as a whole. RESULTS: Among 456 eligible clinicians, 312 in-person surveys were completed by clinicians caring for 152 patients who underwent WMV. Qualitative analyses identified two main themes characterizing high-quality WMV processes: (1) good communication (eg, mutual understanding of family preferences) between the ICU team and family; and (2) medical management (eg, planning, availability of ICU team) that minimizes patient distress. Team member support was identified as an essential process component in both themes. INTERPRETATION: Clinician perceptions of the appropriateness or success of WMV prioritize the quality of team and family communication and patient symptom management. Both are modifiable targets of interventions aimed at optimizing overall WMV.

Psychometric Properties of the Piper Fatigue Scale-12.

Background and Purpose: The Piper Fatigue Scale (PFS)-12 is a recently shortened version of the original PFS that has 40 items. Psychometric evidence for PFS-12 from a small sample of individuals on hemodialysis is presented. Methods: The psychometric analysis with pilot data was done using a detailed item analysis, including Bland-Altman plots, exploratory factor analysis of pre- and post-item scores, and item change scores. Additional measures were used to investigate the validity including the Patient-Reported Outcomes Measurement Information System-Fatigue Scale and the 6-minute walk test. Results: The sample consisted of 86 hemodialysis individuals. The internal consistency reliability of the PFS-12 total scale was 0.91 (pre), 0.95 (post), and subscale alphas were 0.79-0.94. Convergent, concurrent, and predictive validity of PFS-12 were supported. Construct validity of PFS-12 was confirmed predialysis and partially supported in the change score analysis. Conclusion: The brief 12-item PFS is a good alternative to the longer version of this scale to reduce the respondent burden and measure the overall fatigue; further validation in test-retest situations and subscale validity is needed.

Evidence Guiding Withdrawal of Mechanical Ventilation at the End of Life: A Review.

OBJECTIVE: Distress at the end of life in the intensive care unit (ICU) is common. We reviewed the evidence guiding symptom assessment, withdrawal of mechanical ventilation (WMV) process, support for the ICU team, and symptom management among adults, and specifically older adults, at end of life in the ICU. SETTING AND DESIGN: Systematic search of published literature (January 1990-December 2021) pertaining to WMV at end of life among adults in the ICU setting using PubMed, Embase, and Web of Science. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed. PARTICIPANTS: Adults (age 18 and over) undergoing WMV in the ICU. MEASUREMENTS: Study quality was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. RESULTS: Out of 574 articles screened, 130 underwent full text review, and 74 were reviewed and assessed for quality. The highest quality studies pertained to use of validated symptom scales during WMV. Studies of the WMV process itself were generally lower quality. Support for the ICU team best occurs via structured communication and social supports. Dyspnea is the most distressing symptom, and while high quality evidence supports the use of opiates, there is limited evidence to guide implementation of their use for specific patients. CONCLUSION: High quality studies support some practices in palliative WMV, while gaps in evidence remain for the WMV process, supporting the ICU team, and medical management of distress. Future studies should rigorously compare WMV processes and symptom management to reduce distress at end of life.

Dyspnea in Patients with Advanced Stage Cancer: A Nurses Guide to Assessment and Treatment.

OBJECTIVE: To provide oncology nurses with education on the specific distressing symptom of dyspnea in patients with advanced cancer, including proper assessment and a hierarchical approach to both nonpharmacologic and pharmacologic dyspnea interventions. DATA SOURCES: Sources include published research findings, literature reviews, and guidelines, as well as professional opinion from practicing nurses and clinicians. CONCLUSION: Individuals with advanced cancer often experience the distressing respiratory symptom, dyspnea. Assessment tools and treatment recommendations and guidelines are available for clinicians to appropriately evaluate and treat dyspnea. Improved awareness of symptom presence and treatment options will assist nurses in advocating for their patients with advanced cancer and obtaining and delivering the necessary treatments for dyspnea relief. IMPLICATIONS FOR NURSING: Published evidence supports the many treatment options available for dyspnea relief at varying levels. Assessment, individualized treatment, education, and reassessment are key and ongoing to assist patients with advanced cancer to achieve respiratory comfort.

Transportation challenges for persons aging with mobility disability: Qualitative insights and policy implications.

BACKGROUND: Persons aging with mobility disability (PAwMD) experience transportation barriers, which can hinder their ability to fully participate in society. Despite a vast infrastructure of federal laws and programs designed to ensure access to transportation, PAwMD remain a transportation-disadvantaged population. OBJECTIVES: This paper presents detailed insights on transportation challenges experienced by PAwMD along with recent Federal programmatic initiatives designed to enhance access and mobility for transportation for older adults and people with disabilities. To identify policy gaps and opportunities to improve transportation services, we compared individual-level challenges from PAwMD to national survey data about barriers associated with delivering transportation services at state and local levels. METHODS: To assess individual-level transportation challenges, we conducted in-depth, structured interviews with sixty older adult participants with self-identified mobility disabilities for at least 10 years. We also conducted a content analysis of end-user transportation challenges and agency-level transportation coordination barriers to identify correspondences. RESULTS: Participants reported challenges utilizing public and private modes of transportation, related to availability; accessibility; safety; advanced planning; as well as societal attitudes. Barriers to the availability, delivery, and coordination of access and mobility services are linked directly or indirectly to the PAwMD reports of experiencing a shortage of accessible transportation options. CONCLUSIONS: Findings highlight the complexity of federal transportation policies and programmatic initiatives designed to support older adults and people with disabilities, which contribute to implementation barriers and transportation challenges. Results highlight the importance of integrating end-user and state and local provider input into transportation policy development and program implementation.

A review of quality of care evaluation for the palliation of dyspnea.

Assessment and management of dyspnea has emerged as a priority topic for quality evaluation and improvement. Evaluating dyspnea quality of care requires valid, reliable, and responsive measures of the care provided to patients across settings and diseases. As part of an Agency for Healthcare Research and Quality Symposium, we reviewed quality of care measures for dyspnea by compiling quality measures identified in systematic searches and reviews. Systematic reviews identified only three existing quality measurement sets that included quality measures for dyspnea care. The existing dyspnea quality measures reported by retrospective evaluations of care assess only four aspects: dyspnea assessment within 48 hours of hospital admission, use of objective scales to rate dyspnea severity, identification of management plans, and evidence of dyspnea reduction. To begin to improve care, clinicians need to assess and regularly document patient's experiences of dyspnea. There is no consensus on how dyspnea should be characterized for quality measurement, and although over 40 tools exist to assess dyspnea, no rating scale or instrument is ideal for palliative care. The panel recommended that dyspnea assessment should include a measure of intensity and some inquiry into the associated bother or distress experienced by the patient. A simple question into the presence or absence of dyspnea would be unlikely to help guide therapy, as complete relief of dyspnea in advanced disease would not be anticipated. Additional knowledge gaps include standards for clinical dyspnea care, assessment in the cognitively impaired, and evaluation of effectiveness of dyspnea care for patients with advanced disease.

Treatment of Dyspnea in Advanced Disease and at the End of Life.

Dyspnea is a subjective experience of breathing discomfort that consists of qualitatively distinct sensations, varies in intensity, and can only be known through the patient's report. Dyspnea is akin to suffocation and is one of the most distressing symptoms experienced by patients with advanced illness and at the end of life. Common approaches to dyspnea management, such as pulmonary rehabilitation, breathing strategies, or supplemental oxygen, have become accepted through pragmatic use or because studies do not include dyspnea as a measured outcome. Patients and clinicians urgently need evidence-based treatments to alleviate this frightening symptom. To fill this gap, a group of dyspnea researchers with expertise to conduct a literature review of evidence-based interventions for dyspnea in patients with serious illness produced these guidelines. We present the evidence from the strongest recommendations for practice to the weakest recommendations and include practical considerations for clinical nurses.

Respiratory Distress Observation Scale Italian Version: Cultural-Linguistic Validation and Psychometric Properties.

Dyspnea can be assessed using self-rating scales but, as death approaches, self-reporting becomes difficult. The validated Respiratory Distress Observation Scale measures dyspnea distress. The aim of this study was to develop the Italian version of the Respiratory Distress Observation Scale and to examine its psychometric properties. This was a cross-sectional study, analyzing cultural and linguistic validation, content validity, and psychometric properties. Eighty-nine palliative care subjects were enrolled to validate the Italian version of the Respiratory Distress Observation Scale. Patients had an average age of 74.5 (SD, 11.6) years, and 52% (n = 46) were female. Fourteen experts in palliative care evaluated the Italian Respiratory Distress Observation Scale in terms of the content validity ratio and the content validity index (CVI). The Italian Respiratory Distress Observation Scale was reported with an internal consistency (Cronbach α value) of .72 and an overall substantial interrater reliability (Cohen κ method). The Italian Respiratory Distress Observation Scale achieved a scale-level CVI of 93%, an items-level CVI of greater than 86%, and a minimum content validity ratio value of 0.71. A weak positive correlation was found between the Respiratory Distress Observation Scale and the Dyspnea Visual Analog Scale scores (0.374; P < .001). The Italian Respiratory Distress Observation Scale showed good reliability and validity for patients in palliative care. The Respiratory Distress Observation Scale measured respiratory distress in patients nearest to death.

Management of Dyspnea in Advanced Cancer: ASCO Guideline.

PURPOSE: To provide guidance on the clinical management of dyspnea in adult patients with advanced cancer. METHODS: ASCO convened an Expert Panel to review the evidence and formulate recommendations. An Agency for Healthcare Research and Quality (AHRQ) systematic review provided the evidence base for nonpharmacologic and pharmacologic interventions to alleviate dyspnea. The review included randomized controlled trials (RCTs) and observational studies with a concurrent comparison group published through early May 2020. The ASCO Expert Panel also wished to address dyspnea assessment, management of underlying conditions, and palliative care referrals, and for these questions, an additional systematic review identified RCTs, systematic reviews, and guidelines published through July 2020. RESULTS: The AHRQ systematic review included 48 RCTs and two retrospective cohort studies. Lung cancer and mesothelioma were the most commonly addressed types of cancer. Nonpharmacologic interventions such as fans provided some relief from breathlessness. Support for pharmacologic interventions was limited. A meta-analysis of specialty breathlessness services reported improvements in distress because of dyspnea. RECOMMENDATIONS: A hierarchical approach to dyspnea management is recommended, beginning with dyspnea assessment, ascertainment and management of potentially reversible causes, and referral to an interdisciplinary palliative care team. Nonpharmacologic interventions that may be offered to relieve dyspnea include airflow interventions (eg, a fan directed at the cheek), standard supplemental oxygen for patients with hypoxemia, and other psychoeducational, self-management, or complementary approaches. For patients who derive inadequate relief from nonpharmacologic interventions, systemic opioids should be offered. Other pharmacologic interventions, such as corticosteroids and benzodiazepines, are also discussed.Additional information is available at www.asco.org/supportive-care-guidelines.

Models for structuring a clinical initiative to enhance palliative care in the intensive care unit: a report from the IPAL-ICU Project (Improving Palliative Care in the ICU).

OBJECTIVE: To describe models used in successful clinical initiatives to improve the quality of palliative care in critical care settings. DATA SOURCES: We searched the MEDLINE database from inception to April 2010 for all English language articles using the terms "intensive care," "critical care," or "ICU" and "palliative care"; we also hand-searched reference lists and author files. Based on review and synthesis of these data and the experiences of our interdisciplinary expert Advisory Board, we prepared this consensus report. DATA EXTRACTION AND SYNTHESIS: We critically reviewed the existing data with a focus on models that have been used to structure clinical initiatives to enhance palliative care for critically ill patients in intensive care units and their families. CONCLUSIONS: There are two main models for intensive care unit-palliative care integration: 1) the "consultative model," which focuses on increasing the involvement and effectiveness of palliative care consultants in the care of intensive care unit patients and their families, particularly those patients identified as at highest risk for poor outcomes; and 2) the "integrative model," which seeks to embed palliative care principles and interventions into daily practice by the intensive care unit team for all patients and families facing critical illness. These models are not mutually exclusive but rather represent the ends of a spectrum of approaches. Choosing an overall approach from among these models should be one of the earliest steps in planning an intensive care unit-palliative care initiative. This process entails a careful and realistic assessment of available resources, attitudes of key stakeholders, structural aspects of intensive care unit care, and patterns of local practice in the intensive care unit and hospital. A well-structured intensive care unit-palliative care initiative can provide important benefits for patients, families, and providers.

Development and Content Validity of a Respiratory Distress Observation Scale-Infant.

Background: Respiratory distress is one of the most commonly reported symptoms in infants in the neonatal intensive care unit and can lead to substantial morbidity and mortality if not assessed and managed appropriately. Yet, a validated scale for assessing respiratory distress across clinicians in infants is not available. Furthermore, a valid and reliable scale is needed as a dependent measure in studies about infant respiratory distress. Objective: The purpose of this study was to establish a content validity index (CVI) of a modification of the Respiratory Distress Observation Scale© (RDOS) for use with infants who are at least 37 weeks gestational age. Design: The RDOS© was revised using the respiratory characteristics of infants and offered to clinical experts for review. Setting/Subjects: A pool of nine experts in neonatal care, including two neonatologists, two nurse practitioners, one respiratory therapist, two staff nurses, and two nurse scientists, evaluated the revised scale for content validity. Results: The scale CVI was calculated by averaging the item CVIs that were ≥0.80 yielding a scale CVI = 0.96. Our content experts further recommended adding the variable capillary perfusion. Conclusions: Content validity was established. This RDOS-Infant has clinical and research utility if subsequent psychometric testing yields additional acceptable reliability and validity statistics.

Incidence and Risk Model Development for Severe Tachypnea Following Terminal Extubation.

BACKGROUND: Palliative ventilator withdrawal (PVW) in the ICU is a common occurrence. RESEARCH QUESTION: The goal of this study was to measure the rate of severe tachypnea as a proxy for dyspnea and to identify characteristics associated with episodes of tachypnea. STUDY DESIGN AND METHODS: This study assessed a retrospective cohort of ICU patients from 2008 to 2012 mechanically ventilated at a single academic medical center who underwent PVW. The primary outcome of at least one episode of severe tachypnea (respiratory rate > 30 breaths/min) within 6 h after PVW was measured by using detailed physiologic and medical record data. Multivariable logistic regression was used to examine the association between patient and treatment characteristics with the occurrence of a severe episode of tachypnea post extubation. RESULTS: Among 822 patients undergoing PVW, 19% and 30% had an episode of severe tachypnea during the 1-h and 6-h postextubation period, respectively. Within 1 h postextubation, patients with the following characteristics were more likely to experience tachypnea: no pre-extubation opiates (adjusted OR [aOR], 2.08; 95% CI, 1.03-4.19), lung injury (aOR, 3.33; 95% CI, 2.19-5.04), Glasgow Coma Scale score > 8 (aOR, 2.21; 95% CI, 1.30-3.77), and no postextubation opiates (aOR, 1.90; 95% CI, 1.19-3.00). INTERPRETATION: Up to one-third of ICU patients undergoing PVW experience severe tachypnea. Administration of pre-extubation opiates (anticipatory dosing) represents a key modifiable factor that may reduce poor symptom control.

Examination of Community Participation of Adults With Disabilities: Comparing Age and Disability Onset.

Objective: Explore community participation between adults with disabilities ⩽50 and >50 years and between early-(⩽40) and late-(>40) onset disability. Method: A survey examining participation was conducted with a national convenience sample of 692 community-dwelling adults with disabilities. Results: Participants ⩽50 reported presence of more (p < .05) environmental supports for work/volunteer/education and use of transportation. Participants >50 had higher (p < .01) visits to pharmacies; higher (p < .05) evaluative quality of participation (EQOP) at gas stations, exercise facilities, beauty salons/barbers, and use of transportation (p < .01); and more difficulty participating without assistance at grocery stores (p < .05) and gas stations (p < .01). The early-onset group reported higher (p < .05) EQOP at work/volunteer/education and homes of family/friends. The late-onset group reported higher (p < .01) EQOP at exercise facilities; more (p < .05) environmental supports at pharmacies, restaurants, grocery stores (p < .01), doctors' offices (p ⩽ .01), and beauty salons/barbers (p < .01); greater (p < .01) influence of pain/fatigue; and more difficulty without assistance at grocery stores (p < .05) and gas stations (p < .01). Discussion: Understanding these differences can improve interventions to support community participation of individuals aging with disabilities.