Severity of upper and lower extremity functional limitation: scale development and validation with self-report and performance-based measures of physical function. WHAS Research Group. Women's Health and Aging Study.

OBJECTIVES: To better understand disablement and transitions from impairment to disability, discrete valid measures of functional limitation are needed. This study reports the development and criterion-related validity of scales that quantify severity of upper and lower extremity functional limitation. METHODS: Data are from 3,635 cognitively intact community-dwelling women aged 65 years and older and 1,002 moderately to severely disabled participants in the Women's Health and Aging Study. Scales assessing severity of upper and lower extremity functional limitation were constructed from commonly available questions on functional difficulty. Criterion-related validity was evaluated with self-report and performance-based measures. RESULTS: The upper and lower extremity scales range from 0 to 6 and 0 to 9, respectively. Scale scores were well distributed in the disabled group and discriminated limitations in the broader community. For both scales, rates of difficulty for all ADL and IADL increased (p<.001) with increasing severity score, and percent able and mean performance on respective upper and lower extremity tasks decreased (p<.01). DISCUSSION: These scales, constructed from commonly used self-report measures of function, provide discrete measures of upper and lower functional limitation. Because these scales are distinct from measures of disability and impairment, their use should facilitate increased understanding of the disablement process.

Summarizing amount of difficulty in ADLs: a refined characterization of disability. Results from the women's health and aging study.

Activities of Daily Living (ADLs) rating scales often classify older persons as independent or dependent in self-care activities. However, with this type of classification system little information is available on people who, while not dependent, do report some difficulty in performing self-care activities. This 3-year prospective cohort study presents an ADL summary scale that assesses a gradient of difficulty in ADLs for moderately to severely disabled women aged 65 and older living in the Baltimore, Maryland area. At baseline and for each of six interviews done at 6-month intervals, an ADL summary score measuring ADL difficulty was created. ADL summary score slopes were created for each woman who completed at least the baseline and first three follow-up interviews. The baseline ADL summary score and slope of the ADL summary score were used to predict risk of future hospitalization, nursing home admission and death. Additionally, 6-month ADL summary change scores were calculated in order to assess change in the ADL summary score for women who did and did not report an acute event (MI, stroke or hip fracture) at follow-up. The ADL summary scale showed excellent reliability. Intraclass correlation coefficients ranged from 0.83 to 0.93 for measures made one week apart. The 6-month average correlation coefficient was 0.77. The ADL summary scale also performed well in tests of validity. Poorer scores on the ADL summary scale were significantly and inversely related to an objective physical performance scale. The baseline ADL summary score and slope of the ADL summary score predicted future risk of hospitalization, nursing home admission and death. Each unit increase in the slope of the ADL summary score was associated with a 19% (95% CI 1.10, 1.29) increased risk of hospitalization, a 57% (95% CI 1.37, 1.81) increased risk of nursing home admission and a 41% (95% CI 1.22, 1.64) increased risk of death, adjusting for potential confounders. The mean 6-month ADL change score for women reporting an acute event (2.59) was significantly different from those not reporting an acute event (0.52). The strongest and most significant mean 6-month ADL change score was observed for women who reported a hip fracture (4.52) followed by stroke (2.40) and MI (1.00). These results demonstrate that the ADL summary scale presented has validity, reliability and is sensitive to change. This scale, therefore, offers the opportunity to classify functional problems in a larger proportion of the population than do ADL dependence scales. Additionally, it gives us a way to identify earlier functional changes, and a way to track the natural history of functional problems as well as a response to interventions.

The protective effect of emotional vitality on adverse health outcomes in disabled older women.

OBJECTIVE: Although the adverse physical health consequences of negative emotions have been studied extensively, much less is known about the potential impact of positive emotions. This study examines whether emotional vitality protects against progression of disability and mortality in disabled older women. DESIGN: A community-based study, The Women's Health and Aging Study. PARTICIPANTS: A total of 1002 moderately to severely disabled women aged 65 years and older living in the community. MEASUREMENTS: Emotional vitality was defined as having a high sense of personal mastery, being happy, and having low depressive symptomatology and anxiety. The onset of new disability was determined by semiannual assessments of disability in performing activities of daily living (ADLs), walking across a room, walking 1/4 mile, and lifting/carrying 10 pounds. Mortality status was determined by proxy interviews and linkage with death certificates. Survival analyses with time to onset of specific disabilities (among those not disabled at baseline) and time to mortality were performed and adjusted for age, baseline level of difficulty, physical performance, and chronic conditions. RESULTS: Three hundred fifty-one of the 1002 older disabled women studied were emotionally vital. Among women without the specific disability at baseline, emotional vitality was associated with a significantly decreased risk for incident disability performing ADLs (RR = 0.81, 95% CI = 0.66-0.99), for incident disability walking one-quarter mile (RR = 0.73, 95% CI = 0.59-0.92), and for incident disability lifting/carrying 10 pounds (RR = 0.77, 95% CI = 0.63-0.95). Emotional vitality was also associated with a lower risk of dying (RR = 0.56, 95% CI = 0.39-0.80). These results were not simply caused by the absence of depression since protective health effects remained when emotionally vital women were compared with 334 women who were not emotionally vital and not depressed. CONCLUSIONS: Emotional vitality in older disabled women reduces the risk for subsequent new disability and mortality. Our findings suggest that positive emotions can protect older persons against adverse health outcomes.

Gaining and losing health insurance: strengthening the evidence for effects on access to care and health outcomes.

This study uses longitudinal data to examine the consequences of losing and gaining health insurance coverage for access to care and health. For both Medicaid and privately insured persons, compared with those who remained insured, persons losing coverage over a 2-year period were more likely to lack a usual source of care, encounter difficulty in obtaining medical care, be very dissatisfied with ability to obtain needed care, and report no physician visits in the previous 12 months. Uninsured people who gained coverage showed improvement across all indicators of access, in contrast to those who remained without insurance. The effects of changes in coverage on health were in the same direction as those for access, but did not reach statistical significance. This study strengthens the evidence that health insurance coverage has a substantial impact on ability to gain access to medical care and may affect health status.

Caregiving arrangements of older disabled women, caregiving preferences, and views on adequacy of care.

The role of women in caregiving to elderly people has focused primarily on their involvement as givers of care. In contrast, this article focuses on older women as recipients of caregiving. Data from the WHAS and the WHAS Caregiving Study are used to describe: the relationship of caregiving arrangements among moderately to severely disabled older women to sociodemographic, health and functional status; the characteristics of primary family caregivers and the assistance they provide; preferences for caregiving arrangements among both care recipients and caregivers; and views on adequacy of caregiving among older women cared for by family. Overall, about one quarter of these women had no caregiver, reflecting the inclusion in the WHAS of women with only moderate functional difficulty, but close to two-thirds relied on family members, and 15% on paid help only. Greater reliance on family was associated with being age 80 or older, black, and living with others. Women with poorer functioning--more ADL and IADL difficulties, difficulty taking medications without help, low cognitive functioning, not emotionally vital--also were significantly more likely to be cared for by family. Caregiving preferences varied among older women and their husband and daughter caregivers. Husbands consistently viewed in-home family help as the best caregiving arrangement regardless of levels of need. Older women and daughter caregivers both saw nursing homes as the best option for people with dementia and substantial care needs. One-quarter of elderly women chose in-home paid help as the best arrangement for meeting ADL/IADL needs. Older women generally held positive views of the assistance they received from family members. Younger women and lower income women were more likely to indicate they received less help than needed.

Designing a community study of moderately to severely disabled older women: the Women's Health and Aging Study.

PURPOSE: This paper reports on the design of a community-based study focusing on the effects of prevalent and incident disease and other modifying influences, on changes in functioning among moderately and severely disabled elderly women over a 3-year period [the Women's Health and Aging Study (WHAS)]. METHODS: An approach to conceptualizing and assessing disability which captured functional difficulty across a broad range of activities and tasks was developed, tested on existing national data, and used, in the form of a brief screening instrument, to identify moderately to severely disabled elderly women in a large community sample representative of women 65 and older. Women meeting study criteria were recruited for a baseline interview, a 3-hour in-home clinical exam, as well as follow-up interviews and physical performance tests at 6-month intervals for three years. RESULTS: Prevalence of moderate to severe disability among the screened population proved similar to that expected from analysis of national data (about one-third). The screening interview response rate was 78%, and 71% of women eligible by disability criteria participated. Only women completing both the baseline interview and clinical exam were counted as respondents. Analysis of characteristics of participants and nonparticipants indicated no selection bias related to levels of disability. However, education, race, and age were associated with participation. Women with some college education, black women, and younger women were more likely to participate. CONCLUSIONS: The approach used to identify and recruit moderately to severely disabled elderly women in the WHAS is both feasible and applicable to other community-based research where inclusion of elderly people with moderate to severe disability across several areas of functioning is an objective. Other aspects of study design, such as use of proxy respondents, will also affect recruitment of individuals with impaired functioning into epidemiologic studies.

New and worsening conditions and change in physical and cognitive performance during weekly evaluations over 6 months: the Women's Health and Aging Study.

BACKGROUND: Despite the large burden of chronic disease in older persons, especially those with disability, little research has documented changes in symptomatology over short periods of time. Additionally, although it has been demonstrated that medical conditions strongly affect functional level, short-term worsening in condition status has not been investigated for its impact on functional change. METHODS: In a substudy of the Women's Health and Aging Study, 102 women with mild to severe disability received weekly home visits over a 6-month period. Each week they were queried as to the onset of 14 acute, generally self-limited conditions and the worsening or new diagnosis of 12 chronic conditions (condition reporting). They also received a battery of physical and cognitive performance tests. RESULTS: There was a high rate of condition reporting over 24 weekly interviews. Nearly all women reported acute and episodic conditions; the average number of weeks of reporting one or more conditions was 11.8 per woman. For chronic conditions, the average number of weeks of reporting worsening of one or more conditions was 5.2 per woman. Multiple reports of onset or worsening of specific conditions were common, especially for arthritis of the hands, hips, knees, or feet; urinary problems; dizziness or unsteadiness on feet; and back pain. The total number of condition reports and number of weeks of condition reporting were generally not associated with an individual's slope of change in performance tests. For specific conditions, there were generally small and nonsignificant changes in performance in those who reported onset or worsening after 3 or more weeks of not reporting this. CONCLUSIONS: Older disabled women frequently report the onset or worsening of acute and chronic conditions. In weekly observations, these conditions are not related to changes in physical and cognitive performance measures. Possible reasons for this are that (a) condition reporting may not be valid, (b) changes or severity of conditions were of insufficient magnitude to affect functioning, or (c) performance measures are not sensitive to the kinds of changes in chronic and acute conditions that affect people from week to week. We concluded that performance measures are not useful in monitoring modest, short-term changes in health status, but may still be valuable for assessing more major changes in health and functioning over time.

Age differences in ratings of medical care among older adults living in the community.

Patients ratings of care serve as an indicator of quality of care, as well as a predictor of patient behavior. In spite of the heterogeneity of the older population and their disproportionate consumption of health care resources, relatively little attention has been paid to assessing the elderly's satisfaction with medical care. Using data from the 1991 Medicare Current Beneficiary Survey, we compare ratings of medical care and quality of physician care between the young-old (65-79 years) and old-old (80+ years) living in the community. Multivariate logistic regression analyses are performed to assess the independent effect of age on patients' ratings of care. Results show a significant negative association between age and highly positive ratings of care in the elderly; the old-old are less likely than the young-old to give very favorable opinions (e.g., very satisfied vs other) of the care they received. The relationship remains even after controlling for measures of health status and experience and use of health care. However, variations were observed when more negative ratings (e.g., satisfied/very satisfied vs dissatisfied/very dissatisfied) were considered. Although elderly people as a group usually are found to rate their care more positively than younger adults, this study indicates there is heterogeneity in the older population regarding views of medical care.

Association of comorbidity with disability in older women: the Women's Health and Aging Study.

There is substantial evidence that physical disability results from chronic diseases and that the number of chronic diseases is associated with the presence and severity of disability. There is some evidence that interactions between specific diseases are of import in causing disability. Beyond arthritis, however, little is known of the disease pairs that may be important to focus on in future research. This study explores the associations between multiple disease pairs and different types of physical disability, with the objective of hypothesis development regarding the importance of disease interactions. The study population comprised a representative sample of 3841 women 65 years and older living in Baltimore, screened for participation in the Women's Health and Aging Study. The study design was cross-sectional. An interviewer-administered screening questionnaire was administered regarding self-reported physical disability in 15 tasks of daily life, history of physician diagnosis of 14 chronic diseases, and MiniMental State examination. Task difficulty was empirically grouped into six subsets of minimally overlapping disabilities, with a comparison group consisting of those with no difficulty in any task subset. Multiple logistic regression models were fit assessing the relationship of major chronic diseases and of interactions of disease pairs with each disability subtype and with any disability, adjusting for confounders. Fourteen percent of the population reported mobility difficulty only; 5%, upper extremity difficulty only; 9%, both of these difficulties but no others; 7%, difficulty in higher function but not self-care tasks; 7%, self-care task difficulty but not higher function tasks; and 15%, difficulty in both higher function and self-care (weighted data). Almost all in the latter three groups had difficulty, as well, in mobility or upper extremity tasks. In regression models, specific disease pairs were synergistically associated with different types of disability. For example, important disease pairs that recurred in their associations with different disability types were the presence of arthritis and visual impairments, arthritis and high blood pressure, heart disease and cancer, lung disease and cancer, and stroke and high blood pressure. In addition, the type of disability that a disease was associated with varied, depending on the other disease that was present. Finally, when interactions were accounted for, many diseases were no longer, in themselves, independently associated with a given type of disability. Partitioning disability into six subtypes was more informative in terms of associations than was evaluating a summary category of "any disability." These findings provide a basis for further hypothesis development and testing of synergistic relationships of specific diseases with disabilities. If testing confirms these observations, these findings could provide a basis for new strategies for prevention of disability by minimizing comorbid interactions.

Physical disability and social interaction: factors associated with low social contact and home confinement in disabled older women (The Women's Health and Aging Study).

OBJECTIVES: This study examines the association of disability and social interaction, measured as in-person contact with non-household members and home confinement, and identifies sociodemographic, socioeconomic, and health-related factors that modify this relationship. METHODS: Participants were 1,002 moderately to severely disabled community-dwelling women aged 65 and older from the Women's Health and Aging Study, identified by screening an age-stratified random sample of Medicare beneficiaries in Baltimore, Maryland. Logistic regression models were used to estimate the odds of low social interaction associated with disability and each independent modifier. RESULTS: In a typical week, 23% did not visit with anyone residing outside their households and 17% did not leave their homes. In addition to and independent of disability level, older age, not completing high school, having a driver in the home, hearing difficulties and incontinence were associated with low social contact; older age and African American race were related to home confinement. African American women living alone are especially vulnerable to home confinement. DISCUSSION: Physical disability is not necessarily socially disabling, as many of the most severely disabled in our study had at least daily social interaction. Improvements in social interaction appear possible through more effective management of certain health conditions and attention to potential sociocultural barriers.

Emotional vitality among disabled older women: the Women's Health and Aging Study.

OBJECTIVE: To examine correlates of high overall level of emotional functioning (emotional vitality) in disabled older women. DESIGN: A community-based study: The Women's Health and Aging Study. POPULATION: A total of 1002 moderately to severely disabled women aged 65 and older living in the community. MEASUREMENTS: Emotional vitality was defined as having a high sense of personal mastery, being happy, and having low depressive symptomatology and anxiety. Correlations with demographics, health status, and social context were examined. RESULTS: Despite their physical disabilities, 35% of the 1002 disabled older women were emotionally vital. The percent of emotionally vital women declined with increasing severity of disability. After adjustment for disability status, a significantly increased likelihood for being emotionally vital was found for black race (OR=1.69) and for having higher income (OR=1.77), better cognition (OR=2.36), no vision problems (OR=1.61), adequate emotional support (OR=2.54), and many face-to-face contacts (OR=1.64). Having more than one negative life event reduced the likelihood of emotional vitality (OR=0.57). CONCLUSION: A substantial proportion of even the most disabled older women can be described as emotionally vital. Findings also suggest that emotional vitality is not solely a function of stable, enduring individual characteristics but that health status, disability, and sociodemographic context also have an influence on emotional vitality.

Short-term consistency in self-reported physical functioning among elderly women: the Women's Health and Aging Study.

The assessment of physical functioning and disability is integral to population-based and clinical research carried out among elderly people. Typically, functional status is measured through self-reported responses to questions of the form "Do you have difficulty [doing a specific task]?" Knowledge of the reliability and validity of these self-report measures is key to the interpretation of many research efforts, but data on these measurement parameters are sparse. This paper addresses this deficiency through analyses of data from the Weekly Substudy of the Women's Health and Aging Study, a cohort of Baltimore-area women aged > or =65 years with moderate to severe physical disability. Self-reported data on 20 activities, obtained weekly over a 6-month period in 1993 or 1994, were analyzed to investigate how time intervals between assessments and a subject's age and baseline level of disability influenced the consistency of self-reports of disability at both the population level and the individual level. The prevalence of self-reported difficulty increased with baseline disability and, to a lesser extent, with age group. Consistency for all items was very high over short time intervals, but it decreased substantially with increasing intervals between responses (although associations between responses remained significant at 24 weeks). Consistency did not vary with age or baseline disability. Graphic techniques and statistical methods for use with repeated binary data are also illustrated.

Assessment of medical care by elderly people: general satisfaction and physician quality.

OBJECTIVE: To identify personal characteristics and factors related to health and patterns of healthcare utilization associated with the elderly people's satisfaction with medical care. DATA SOURCES/STUDY SETTING: Data from the 1991 Medicare Current Beneficiary Survey (MCBS) on 8,859 persons age 65 and over living in the community. STUDY DESIGN: Items reflecting general satisfaction with care and views of physician quality are examined and, based on factor analysis, grouped in dimensions of two (global quality, access) and three (technical skills, interpersonal manner, information-giving), respectively. The relationship of high levels of satisfaction in each dimension to personal characteristics of elderly people, and to measures of access and utilization, is assessed using logistic regression. PRINCIPAL FINDINGS: While satisfaction is high, with over 90 percent surveyed expressing some satisfaction, there is substantial variation with less likelihood of high satisfaction among those 80 or older, with less education and income and in poorer health. Longer waiting time at visits and less frequent visits are factors in lower satisfaction as well. A favorable perception of physician quality, especially regarding technical skills, appears to play a significant role in satisfaction with global quality of care. CONCLUSIONS: Studies of patient satisfaction in elderly people are rare. Some factors expected to be related to positive assessment based on earlier studies, were, e.g., better health and shorter waiting time, while others were not, e.g., increasing age. Elderly people appear to place greater importance on physician technical skills, as opposed to interpersonal dimensions, in assessing global quality. These findings suggest the need for a better understanding of how elderly people evaluate care and what they value in interactions with the healthcare system.

The prevalence and impact of self-reported hip fracture in elderly community-dwelling women: the Women's Health and Aging Study.

To estimate the prevalence and impact of self-reported hip fracture in elderly women an age-stratified random sample of 3841 community-dwelling women aged 65 years and above were interviewed to determine the occurrence of 13 chronic conditions and difficulty performing 15 tasks. Associations were examined using multiple logistic regression analysis. The weighted prevalence of hip fracture was 4.7 per 100. Prevalence increased with increasing age from 2.9 per 100 in women aged 65-74 years to 12.6 per 100 in women aged 85 years and above, and was higher in white women than black women. Women with hip fracture were significantly more likely to report concomitant Parkinson's disease (age-adjusted odds ratio [aOR] = 2.8) and stroke (aOR = 1.8). After adjustment for potential confounding variables, women with hip fracture were significantly more likely to report difficulty performing 11 activities that map into domains of mobility/exercise tolerance, self-care tasks and higher functioning domains. Hip fracture is common among elderly community-dwelling women and is associated with difficulty in performing activities of daily living.

Measuring quality of life in dementia: conceptual and practical issues.

The authors discuss some of the challenges that exist in measuring quality of life in persons with dementia. The issues that arise in measuring QOL in persons with dementia are identified, and the status of instruments that exist or are being developed is reviewed briefly.

Caregiver role appraisal and caregiver tasks as factors in ending caregiving.

This study focuses on factors related to why people with primary responsibility for providing care to ADL-impaired elderly persons ended their caregiving roles. Data are from the 1982 National Long-Term Care Survey and the Informal Caregiver Survey. Variables reflecting characteristics of care recipients and caregivers, caregiver role responsibilities, and appraisal of the caregiver role are investigated. Of particular interest is the influence of role responsibilities, such as number of ADL tasks, relative to appraisal of the caregiving role. The results indicate that factors other than role responsibilities are important in understanding who ends caregiving, and that risk factor profiles may prove a useful means of targeting caregivers at greatest risk of ending caregiving.

Satisfaction with medical care among elderly people in fee-for-service care and an HMO.

This study investigates satisfaction with care among elderly Medicare beneficiaries enrolled in a health maintenance organization (HMO) and beneficiaries in fee-for-service (FFS) care in the same geographic area. Satisfaction with two dimensions of care, access/quality and costs, are examined, to investigate differences in enrollee/FFS evaluation of these dimensions of care as well as predictors of satisfaction with care. In addition, satisfaction among healthy and chronically ill elderly people in these two care settings is explored. Results indicate higher satisfaction with access/quality of care among those in FFS and higher satisfaction with costs among HMO enrollees. These relationships hold controlling for other variables and among the chronically ill elderly. Sources of variation in satisfaction are somewhat different among the HMO and FFS elderly. Satisfaction with paperwork and ease of getting to care, however, influences satisfaction with other aspects of care in both populations.

Do HMOs reduce health care costs? A multivariate analysis of two Medicare HMO demonstration projects.

Charge data from two Medicare HMO demonstration projects were analyzed to determine if prepaid plans achieved cost savings for enrolled beneficiaries. Fallon Community Health Plan of Massachusetts did not reduce total charges significantly for survivors in their first year postenrollment. However, the plan enjoyed reductions in total charges per month after the first year of nearly 38 percent (41 percent for Part A; 31 percent for Part B). Savings for decedents were more modest, reducing total charges per month by around 27 percent (19 percent, Part A; 68 percent, Part B). Greater Marshfield Community Health Plan of Wisconsin was not successful in controlling charges during the demonstration period. Marshfield incurred losses in the first postenrollment year for survivors due to a 38 percent increase in total charges per month (18 percent, Part A; 73 percent, Part B). In the second year postenrollment, the Marshfield plan was able to reduce losses for survivors to roughly 11 percent (-6 percent, Part A; 44 percent, Part B). For decedents, Marshfield experienced an increase in total charges per month of approximately 21 percent relative to fee-for-service comparisons, with Part B charges again much higher than those of the comparison group (47 percent).