A cost-effectiveness analysis of a health education programme for elderly persons with age-related macular degeneration: a longitudinal study.

PURPOSE: To analyse the cost-effectiveness of the activity-based Health Education Programme 'Discovering New Ways' versus a standard Individual Programme. METHOD: Two-hundred and twenty-nine persons were randomized to either the Health Education Programme or an Individual Programme. The present study is based on 131 persons who participated in the 28-month follow-up. Costs for the low vision clinic were documented prospectively along with external costs. A cost-effectiveness analysis was done using cases with an improved level of perceived security in daily activities as the effectiveness measure. RESULTS: The Health Education Programme led to significantly more cases with an improved level of perceived security (45 vs. 10%, CI 95%: 21-49, p value < 0.001) and the total social cost per treatment was lower (28,004 vs. 36,341 SEK). Taken separately the low vision clinic costs were slightly higher due to a higher prescription of assistive devices, but external costs were lower for the Health Education Programme compared to the Individual Programme, though neither of these differences was statistically significant. CONCLUSION: The results suggest that replacing the standard Individual Programme with the Health Education Programme 'Discovering New Ways' is cost-effective as more persons experience increased security to a lesser total cost.

Assistive devices in activities of daily living used by persons with age-related macular degeneration: a population study of 85-year-olds living at home.

The purpose of this study was to investigate the overall use of assistive devices among persons with age-related macular degeneration (ARMD) and how it is related to dependence in daily activities. This was a retrospective, descriptive, cross-sectional population study of 85-year-olds. The most common category of assistive devices was bathing devices followed by mobility devices. The overall use of assistive devices was 82%, and around 80% of the device users were independent in activities of daily living. They were multiple device users (57%) and used more mobility devices and personal assistance in mobility. In conclusion, the ARMD group comprises very frequent users of assistive devices and uses assistive devices to remain independent. This implies that health services should provide assistive devices at an early stage in the disablement process to avoid the development of dependence and should consider the likelihood of multiple health problems when assessing the needs of assistive devices among persons with ARMD.

Assistive devices in an elderly population studied at 70 and 76 years of age.

The longitudinal Intervention Study of the Elderly in Göteborg, Sweden (IVEG), has provided an opportunity to report on the use of assistive devices in activities of daily living (ADL) in a subsample of elderly persons living in their own homes, who were interviewed at the ages of 70 and 76 (n = 371). Type, frequency, usage rate and effectiveness of assistive devices was studied among all 76-year-olds involved in the IVEG study (n = 595). One-fifth at the age of 70 and almost half of the population at 76 had assistive devices, most frequently in connection with bathing and mobility. A higher percentage of females and subjects living alone used assistive devices compared to men and cohabitants. The longitudinal study showed that 31% developed a need for assistive devices between 70 and 76 years of age, 15% used assistive devices both at 70 and 76 years, while 50% had no devices at 70 or at 76 years of age. The usage rate was high (90%), and a high degree of effectiveness was found, particularly in the form of an increment in safety and a decrement in effort in the various activities.

Use of assistive devices in daily activities among 85-year-olds living at home focusing especially on the visually impaired.

PURPOSE: The purpose was to investigate the use of assistive devices in daily activities and its relation to daily activities. METHOD: 85-year-old persons (n = 617) were studied in a descriptive, cross-sectional population study. RESULTS: The overall use of assistive devices was 77% in the total population of 85-year-old persons and the results show that persons who have visual impairment use more assistive devices. The most common category of assistive devices in the population was connected with bathing followed by mobility devices. The majority of the assistive device users in all groups were independent in both instrumental (I-ADL) and personal daily activities (P-ADL). There was a statistically significant higher proportion of device users who were independent in daily activities in the normal vision group compared to the visual impairment groups. There was already a significant difference in the use of assistive devices at a visual acuity level of 0.7-0.5 compared to participants with normal vision. CONCLUSION: The results show that it is imperative to provide intervention such as assistive devices in P and I-ADL earlier in the disablement process in order to slow down the progression of decline, as persons with visual impairment are at high risk of developing disability.

Activities of daily living studied longitudinally between 70 and 76 years of age.

Functional performance, i.e. personal and instrumental activities of daily living (P-ADL, I-ADL), was studied in a population of 70-year-old persons followed to the age of 76, and with an intervention period included between the ages of 70 and 73. At age 70 (n = 617), 83% were independent, 13% were dependent in I-ADL and 4% dependent in I+P-ADL. Among the independent subjects, the 6-year outcome in mortality was 13%. Dependence at 70 predicted mortality as well as institutionalization, and the risk was higher for those dependent in P+I-ADL than for persons dependent in I-ADL only. Of participant survivors the incidence of disability was 30% (8% between 70 and 73, 26% between 73 and 76 years of age) and was dominated by dependence in I-ADLs. The intervention did not lead to less dependence in ADL at age 76. Gender differences were found at age 76 in cooking, bathing and dressing, males being more dependent in such activities. At 70, 73 and 76 years of age, assistance given by relatives dominated.

Long-term evaluation of a health education programme for elderly persons with visual impairment. A randomized study.

UNLABELLED: In order to implement evidence-based practice, a randomized study was set up to evaluate the ADL- based Health Education Programme 'Discovering new ways' for elderly persons with age-related macular degeneration. PURPOSE: To investigate the impact of this program on perceived security in the performance of daily activities 28 months after the intervention. METHOD: Two-hundred and twenty-nine persons randomized to either the Health Education programme or an Individual Intervention Programme participated in the study. At the 28-month follow-up there was a dropout of 98 persons and the results are based on 62 persons participating in the Health Education Programme and 69 persons in the Individual Intervention Programme. RESULTS: There were statistically significant differences in perceived security between the groups in 15 out of 28 daily activities. Furthermore, the Health Education Group showed a significant tendency towards an improved level of security while the Individual Intervention Group tended to deteriorate. CONCLUSIONS: The findings provide strong support for the long-term effect of the programme and for the implementation of evidence-based practice. The study corroborates the effectiveness of the Health Education Programme in enhancing security and hindering a progressive decline in perceived security in daily activities.

Development of an ADL instrument targeting elderly persons with age-related macular degeneration.

BACKGROUND: In order to estimate the needs of early intervention in a health education program, an ADL instrument measuring feelings of (in)security was needed. The instrument was intended to detect early signs of decline and to evaluate ADL performance among persons with AMD. An evaluative instrument must have a high level of responsiveness, which is the ability to detect true changes over time but must also show a high level of intra-individual agreement in a test-retest assessment. PURPOSE: The purpose of this study was to develop an ADL instrument for evaluative purposes and to establish the reliability and the responsiveness of the instrument. METHOD: The target group comprised all persons referred by an ophthalmologist for low vision rehabilitation, 65 years and older, living at home, with aged-related macular degeneration as the primary diagnosis and with distance visual acuity of the better eye with best correction not lower than 0.1. A non-parametric statistical method that is developed for paired ordered parametrical data was applied in order to measure the systematic and occasional intra-rater disagreement separately and to measure the responsiveness. CONCLUSION: The test-retest study showed that the ADL-instrument had a high level of test-retest stability, which is a condition for responsiveness. The instrument was found to be responsive. It could therefore detect true longitudinal changes and be used for evaluative purposes targeting elderly with AMD.

On the use of the WHO handicap classification in a population study of 73- and 76-year-old men and women.

The WHO ICIDH classification of handicap was used in a population sample studied at 73 (n = 504) and 76 (n = 649) years of age. In the sample, there was either no handicap at all or the degree of handicap was generally low. In most handicap categories, however, the grades increased from 73 to 76 years. The self-rated activity level and the handicap category Occupation showed only low correlation. Good agreement was found between the handicap category Physical independence and assessments of Personal and Instrumental ADL and there was also a correlation between Mobility and maximal walking speed. Correlations were found between the handicap categories and the dimensions in the Nottingham Health Profile (NHP), but r-values were generally rather low. The highest correlation was that with the dimension of Physical mobility. The difference between self-assessed health aspects of quality of life and observer ratings using given norms is stressed.

A health education program for elderly persons with visual impairments and perceived security in the performance of daily occupations: a randomized study.

OBJECTIVE: The purpose of this randomized, longitudinal study was to investigate the impact of a health education program on perceived security in the performance of daily occupations 4 months after the intervention period. METHOD: Two groups of persons with age-related macular degeneration were compared: Those who had followed a newly developed health education program that was based on occupation and those who took part in a standard individual intervention program. RESULTS: Significant differences in the level of perceived security between the groups were found for 13 of 28 occupations. Participants in the health education group maintained or improved their level of perceived security in 22 daily occupations, whereas those in the individual intervention group declined to a lower level in 17 daily occupations. CONCLUSION: This study provides support for the effectiveness of the health education program to enhance security and hinder a progressive decline in perceived security in daily occupations.

Longitudinal studies of dependence in daily life activities among elderly persons.

Ability in activities of daily living (ADL), use of assistive devices, and relation to functional limitations and impairments were studied among persons between 70 and 76 years of age within the Inter-Vention study of Elderly in Göteborg (IVEG) Sweden. An ADL index was developed including instrumental activities (I-ADLs) (cleaning, shopping, transportation and cooking), which was combined with Katz' Index of personal daily life activities (P-ADLs) (bathing, dressing, going to the toilet, transfer, continence and feeding). Independence of and dependence on assistance from another person was assessed and it was possible to classify performance according to an ordinal scale of ADL-steps. The reliability and validity of the scale were tested in an out-patient sample (n = 85) as well as in a population of 76-year-olds (n = 659) and were found to be sufficient (coefficients of reproducibility and scalability, internal consistency, inter- observer reliability, content, construct, and criterion validity). The "Staircase of ADL" can be used for observation and documentation of different levels of ability/disability for individuals, groups and for population studies. Most persons (83%) were independent in all activities at age 70 (n = 617). Among survivors followed longitudinally, the incidence of disability was 8% between 70 and 73 and 26% between 73 and 76 years of age. Dependence at age 70 could predict mortality as well as institutionalization. No sex differences were found in the proportion with overall disability. Assistance given by relatives dominated both at 70, 73 and 76 years of age. One fifth at age 70 and almost half of the population at age 76 used assistive devices (AD) in daily life activities, and the use was more frequent in women (52%) than men (37%) at age 76 (n = 595). During the studied age interval, 39% "new users" were found, while 22% were "temporary users". The usage rate was high and the effectiveness of ADs increased the person's ability to master the situation, especially evident as increased safety and reduction of effort in activities of daily living, implying a reduced degree of handicap. Physical impairments and functional limitations had a considerable impact on dependence in daily life activities as persons dependent in ADL had lower maximal walking speed, grip strength, knee extensor strength, stair-climbing capacity and forward reach than those who were independent in ADL (n = 602). Walking speed in both women and men and sight impairment in men had the greatest influence on dependence in ADL. Women and men who stayed independent over the period (70-76) had significantly higher maximal walking speed and knee extensor strength at the age of 70 than those who became dependent or were dependent on both occasions.

Measures of individual and group changes in ordered categorical data: application to the ADL staircase.

The aim was to describe the application of a non-parametric method to a study of changes in activities of daily living (ADL) measured by a 10-level ordinal scale, the Staircase of ADL, in a population of 70-year-old persons followed to the age of 76 (n = 371). The statistical method takes account of the fact that change cannot be defined by differences and can separately measure the level of change for the group and for the individuals. This is demonstrated step by step. Measures of change for the subgroups, men and women, are also given. As a group, there was a systematic increase in ADL dependence between the ages of 70 and 76 years. The individual pattern of change was more dispersed between 73 and 76 years of age. Individual variations in ADL changes with increasing age were small compared to the systematic change for ADL for the subgroups of men and women. The systematic change in ADL follows a pattern with "one step at a time" for women and "many steps at a time" for men. In conclusion, this new statistical method provides a valuable tool for detailed information of individual as well as group changes in longitudinal studies.

The cumulative structure of personal and instrumental ADL. A study of elderly people in a health service district.

Katz' Index of ADL has been supplemented by five well-defined instrumental activities, namely cooking, washing, transportation, cleaning, and shopping. Eighty-five persons, mainly elderly, who had consecutively consulted a district occupational therapist, were assessed in their homes in order to study the reliability, the scalability, and the validity of the expanded index. The inter-observer reliability was high. The coefficient of scalability was well above the acceptance level, indicating construct validity. No person was dependent in personal ADL and totally independent in instrumental ADL. Persons who were dependent in both personal and instrumental ADL were older and lived in sheltered accommodation more often than persons who were dependent only in instrumental ADL, indicating external validity. This study shows that there was a cumulative relationship between certain well-defined instrumental activities and between personal and instrumental activities. This supplemented index can be useful for assessing and differentiating the need for personal assistance and homecare among disabled elderly people.

Assessment of activities of daily living in the elderly. A study of a population of 76-year-olds in Gothenburg, Sweden.

The cumulative structure of personal daily activities (Katz' Index of ADL) and four well-defined instrumental activities (cooking, transportation, shopping, and cleaning) have been studied in a population of 76-year-olds (N = 659) in Gothenburg, Sweden. Sixty-five percent of the population were independent, 22% were dependent in instrumental activities, and 13% were dependent in both instrumental and personal activities. No person was dependent in personal ADL and independent in instrumental ADL. The internal consistency and the coefficient of scalability were well above the acceptance level, which indicated an internal reliability and validity of the new scale. The frequency of personal and home-assistance care, type of accommodation, self-assessment of self-care and domestic activities were compared with the level of dependence in ADL and indicated external validity. This cumulative instrument of ADL can be used to describe and compare the level of disability in elderly populations and to define the need for personal assistance in home care among disabled persons.

Dietary intake and functional ability between 70 and 76 years of age.

Functional ability as well as the sociological, psychological, physiological, and nutritional status are important parts of the multi-dimensional problems of older persons. The aim was to study the relationships between ability/disability in daily life activities (ADL) and dietary intake in elderly persons studied longitudinally between 70 and 76 years of age (N = 97) in Göteborg, Sweden. People living in sheltered accommodations were excluded. Dependence in ADL was measured by "The Staircase of ADL"; dietary intake was measured by a Diet History (DH) questionnaire. Most persons had no difficulties, or were dependent on personal help in ADL at age 70 (females 70%, males 80%), but the proportion decreased at the age of 76 (females 43%, males 54%). The sample was divided into subjects without disability both at 70 and 76 years of age (N = 41), subjects disabled only at 76 (N = 31), and subjects disabled both at 70 and 76 years of age (N = 20). Food choice was not affected by disability neither at age 70, nor at age 76. Dietary intake decreased between 70 and 76 years in all three groups. However, despite the fact that one could have expected a relationship between food and nutrient intake, and ADL, we did not find significant relationships. The main reason might be that the group is relatively young, and with ADL problems mainly in instrumental ADLs. It might, therefore, be anticipated that such trends could be more marked in higher age groups.

Instrumental activities of daily living related to impairments and functional limitations in 70-year-olds and changes between 70 and 76 years of age.

The aim of this study was to analyse in particular dependence in instrumental daily life activities (I-ADLs) and its association with physical impairments and functional limitations in the elderly. The study was based on cross-sectional data on 70-year-olds (n = 602) and longitudinal data on subjects followed up to the age of 76 (n = 371). Persons dependent in ADL had lower values in maximum walking speed, grip strength, knee extensor strength, stair climbing capacity and in forward reach, compared with those who were independent in ADL. Walking speed in both women and men and sight impairment in men had the greatest influence on dependence in ADL. Possible critical levels for disability in ADL are discussed, as persons who developed dependence between 70 and 76 already had a lower capacity in walking speed and knee extensor strength at age 70 than persons who retained their independence in ADL.

The use and effectiveness of assistive devices in an elderly urban population.

The aim of this study was to examine the type, frequency and usage rate of assistive devices in daily life activities in a community-based population aged 70 and over (N = 170), as well as the particular part of the intervention trial which focused on un-met needs, and the usage rate and effectiveness of assistive devices 6 and 12 months after prescription. Among persons under 80 years of age, 24% were users of assistive devices; in the 80 years or above group, this figure rose to 57%. Hygiene and mobility devices were the most common. The usage rate of assistive devices was 84%. The reasons for disuse were an improved health status, or difficulties in using the device. Sixteen percent of the study population had un-met needs of assistive devices. At follow-up visits, the subjects estimated a high degree of effectiveness when using the devices, particularly in the form of reduced difficulty and increment of safety, and increased capacity and ability in various activities. We conclude that the use of assistive devices increases with age, and that most of the assistive devices are used and are effective. As the need for assistive devices changes over time, follow-ups in the home are necessary. Therefore, to meet the needs of a growing elderly population, information about assistive technology should be supplied to both personnel in health care and in the social service system.

Cognitive function and functional ability. A cross-sectional and longitudinal study at ages 85 and 95 in a non-demented population.

We studied the relationship between cognitive function and ability in daily life activities (ADL) at ages 85 (N=332) and 95 (N=63) cross-sectionally and longitudinally in representative populations of non-demented persons, in order to focus on manifestations related to healthy aging. Among the 85-year olds, 31% were independent, 42% were dependent on personal assistance in instrumental ADL (IADL) and 27% in personal ADL (PADL); the corresponding figures for the 95-year olds were 8, 40 and 52%, respectively. Regarding the relationship between cognitive function and ADL, the analysis could only be performed in the cross-sectional data. At age 85 a significant trend was found regarding nearly all cognitive tests for both men and women, indicating that subjects who were ADL-independent had better results than those dependent in IADL, and both IADL and PADL. At age 95, no such trend was found in males, but in females the trend was significant, and those dependent in ADL had poorer results in the separate cognitive tests. By combining the different cognitive tests into a compiled cognitive index, it was seen that the most ADL-dependent persons were more cognitively impaired both at ages 85 and 95, compared to persons who were ADL-independent. Not only cognitive functioning (OR 3.3), but also mobility (OR 4.9) and tiredness (OR 3.3) were independent predictors for ADL-dependence among the 85-year olds.

Functional balance tests in 76-year-olds in relation to performance, activities of daily living and platform tests.

Functional balance was studied in a sample of 98 women and 75 men from a population study. Tests used were one-legged stance and walking in a figure of eight. The results revealed that both static and dynamic functional balance were significantly correlated to isometric knee extensor strength, walking speed and stair-climbing capacity, while the association with activities of daily living (ADL) was modest in this sample of relatively healthy elderly persons. A sub-sample of 17 women and 10 men also performed balance tests on a force plate. Velocity of the sway path with both open and closed eyes was significantly correlated to the functional balance tests. Mean sway in the anterior-posterior direction and area tested with closed eyes were significantly correlated to the functional static balance test. There were no significant associations between the platform variables and the results in the performance tests. This study demonstrated differences between the sexes in that males were able to stand for a longer time on one leg, while they swayed more than females on the platform.

Different kinds of services and informal support in the daily life activities in a community-based elderly population.

As part of the well-known population study of 70-year olds in Gothenburg, 1239 persons at the age of 70 were invited to participate in an extensive investigation and Inter-Vention program of the Elderly in Gothenburg (IVEG). The probands were examined at the ages of 70, 73 and 76 years. The purpose of this study is to describe different kinds of services and informal support in the daily life activities among three large groups of people in their seventies. A cross-sectional study design was chosen in order to get as large groups as possible. A home call was made by an experienced occupational therapist, who interviewed and observed the probands' performance in the daily life activities. The probands and their relatives were asked about the extent of different services and informal support. Personal and home assistance care given by relatives almost doubled between the age of 70 and 76 years. Help organized by the Social Welfare Services only increased marginally. Of the personal activities of daily living (ADL), getting in/out of a bathtub was the activity that caused most problems. The most common walking aid was a stick or a crutch, while use of a wheelchair was quite uncommon. Between the age of 70 and 76 years, the use of the Handicap Transport Service more than doubled. This study shows that at the age of about 73 years the elderly should be offered formal support, such as the supply of assistive devices. What is noteworthy is that the help from relatives and friends increased much more than the help from the Social Welfare Services between the age of 70 and 76 years. At present, relatives and friends assist the elderly in their homes to a large extent, and frequently. Relatives are doing an important job for their elderly and for society, and should be given every possible kind of public support and relief in order to have the strength to continue.