22 CHAPTER 2 Implications of an Aging Population for Rehabilitation ng,active 01 condition me for health professionals.More accessible health care and nt in er health. edical ad more have improved the survivorship of individuals with mul- cn successive gen MORBIDITY 19, Prevalent Chronic Conditions ne chronic Emphysema preva L h disease.stroke.diaberes.hearing and vision impair omly dispersed through- FIGURE 2-6 C years and out th um pop disease is more prevalent among men than women, whereas nor experie often tha abetes affectsmen Hispanics and pon-Hisp anic blacks is eater than older tion is always in order when interpreting subgroup sta non-Hispanic whites.Osteoporosis is four times more tistics.First,the definitions for complex concepts such as c status may shift over of Phedd m s ve een imperfectly ap. er. or under sented in statistical anal Prevalent Activity Limitations our The concepts themselves may be proxy measures of other Estimates from factors that affect health status and function,such as ad are nan abili anage,lif nd de e suggested this trend was improving,it may actually be findings may be highly correlated,which,for example worsening.4 Furthern more,these surve that demographers uncertain a to whether race the the icity or or educational atta nment Dette disabling c ditio such as arthritis) nonwhites and of view reater explanatory wer of a particular obese individuals.14 As has been noted in the overall rariable in a more robust sta tical model)Further. health status of the general populati it is commonly agree that th ty are ay not be or para and may dispropo inter n.ince or health As we shift from exploring population characteristics tus.altern tively,the models that are used to explain associated with biological phenomena such as mortality functional deficits or activity limitations may not be
22 CHAPTER 2 Implications of an Aging Population for Rehabilitation gains in overall life expectancy are important indicators of a nation’s well-being, active life expectancy, that is, the years spent without a major infirmity or disabling condition, may provide more meaningful information for health professionals. More accessible health care, improved understanding of genetic predisposition, and preventive behaviors such as increased physical activity and balanced nutrition have all contributed to more years spent in better health. Although medical advances have improved the survivorship of individuals with multiple impairments in old age, the data support the notion that each successive generation of older adults enjoys a slightly greater active life expectancy prior to entering permanent functional decline.4,6 MORBIDITY Prevalent Chronic Conditions The proportion of older adults at any age without any chronic conditions is small. About 80% have at least one chronic condition and 50% have two or more.6 Among these, arthritis is the most prevalent self-reported condition causing an activity limitation. Hypertension, heart disease, stroke, diabetes, hearing and vision impairments, and fractures also take their toll on activity.4,6 Chronic conditions are not randomly dispersed throughout the population (Figure 2-6). Arthritis is more common among women. Hypertension is more prevalent among women and blacks than men and whites. Heart disease is more prevalent among men than women, whereas non-Hispanic blacks tend to experience stroke more often than other subgroups. Diabetes affects men and women about equally, but prevalence among older Hispanics and non-Hispanic blacks is greater than older non-Hispanic whites. Osteoporosis is four times more likely among women and substantially increases the risk of fracture.4,6 Prevalent Activity Limitations Estimates from a number of national surveys indicate that a substantial proportion of older adults are hampered in their ability to perform a major life activity or are limited in mobility, and despite some studies that suggested this trend was improving, it may actually be worsening.14 Furthermore, these surveys indicate that these limitations in function increase with age, and they are generally worse for women (who may contract more disabling conditions such as arthritis), nonwhites, and obese individuals.6,14 As has been noted in the overall health status of the general population, it is commonly agreed that the risks of physical disability are higher for nonwhites and individuals with lower socioeconomic status.6 As we shift from exploring population characteristics associated with biological phenomena such as mortality to consider the functional status of various groups, which is a biopsychosocial phenomenon, a word of caution is always in order when interpreting subgroup statistics. First, the definitions for complex concepts such as race/ethnicity or socioeconomic status may shift over time from survey to survey, or have been imperfectly applied during data collection so that some subgroups are over- or underrepresented in statistical analyses. The concepts themselves may be proxy measures of other factors that affect health status and function, such as educational advantage, lifetime employment opportunity, or living environment, but are very difficult to measure directly and rarely studied.15 Statistically, these findings may be highly correlated, which, for example, leaves demographers uncertain as to whether race/ ethnicity or poverty or educational attainment better explains poor health status from a statistical point of view (i.e., greater explanatory power of a particular variable in a more robust statistical model). Furthermore, even highly correlated relationships among variables may not be linear or parallel and may disproportionately affect individuals at different points on the intersecting continua of education, income, or health status. Alternatively, the models that are used to explain functional deficits or activity limitations may not be 100 90 80 70 60 50 40 30 20 10 0 Percent Men 37 26 52 54 10 8 Heart disease Hypertension Stroke Asthma Chronic bronchitis or Emphysema Cancer Diabetes Arthritis Women Percentage of people age 65 and over who reported having selected chronic conditions, by sex, 2005-2006 Note: Data are based on a 2-year average from 2005-2006. Reference population: These data refer to the civilian noninstitutionalized population. Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey. 1012 11 10 24 19 19 17 43 54 FIGURE 2-6 Chronic conditions among adults age 65 years and older by sex. (From Federal Interagency Forum on Aging-Related Statistics: Older Americans 2008: key indicators of well-being. Washington, DC: U.S. Government Printing Office, March 2008.)
CHAPTER 2 Implications of an Aging Population for Rehabilitation 23 such as socioeconomic status and physiological impair antly for physical therapists,exercise and phys ment.Therefore,at the level of the individual person, cal a activity are not only critical interventions once health which is the level conditions develop! but they provide broad health t the or on op lay he can assum mographic factors and health status or quality of life are sical activ ity to achieve primar ntion and risk more tentative and,more than occasionally,not particu- reduction for development of several healh condition larly useful t actors outsi the c cian's contro Disease and Disability Comorbidity and Disability The six most common chronic health conditions that It is not unust are arth and other mus patients with th Inty ar ely to problems.vision or hear s.fractures and of the gen sis of functional def joint injuries,diabetes,and mental illness (Figure 2-7). cit but treatment as well.For example,the individual 18to44☐45to64☐65to74☑☑75 andode 2.0 73.2 ☑193.1 54 He 455 ☑17o.9 42 Vision/hearin 13,8 312 ☑2.5 6.8 15.9 25A 77777777☑48.6 126 Diabete 18.5 7777777☑42.5 10. Mental illnes 18.6 0 soc2earC8nSro9ear5an2502aee192ForuemalOm8eeeocastendotchapiar
CHAPTER 2 Implications of an Aging Population for Rehabilitation 23 robust and multidimensional so that the statistical analyses incorporate data gathered from multiple domains such as socioeconomic status and physiological impairment.16 Therefore, at the level of the individual person, which is the level at which we measure activity limitation, functional deficit, or disability, inferences from these models about the interplay between broad sociodemographic factors and health status or quality of life are more tentative and, more than occasionally, not particularly useful to clinical decision making as they represent factors outside the clinician’s control. Disease and Disability The six most common chronic health conditions that result in activity limitations are arthritis and other musculoskeletal conditions, heart and other circulatory problems, vision or hearing impairments, fractures and joint injuries, diabetes, and mental illness (Figure 2-7).6 Increasing age is associated with increasing prevalence of activity limitations, with the exception of mental illness. Importantly for physical therapists, exercise and physical activity are not only critical interventions once health conditions develop17-19 but they provide broad health promotion opportunities. Physical therapists can assume a key role in public health by instruction in exercise and physical activity to achieve primary prevention and risk reduction for development of several health conditions (heart and circulatory disorders, fractures associated with falls, and diabetes).20-22 Comorbidity and Disability It is not unusual for physical therapists to find that the patients with the most disability are also likely to have a number of medical or health conditions that complicate not only understanding of the genesis of functional deficit but treatment as well. For example, the individual Note: The reference population for these data is the civillian noninstitutionalized population. Source: National Center for Health Statistics, 2002a, Figure 17. For full citation, see references at end of chapter. 18 to 44 45 to 64 65 to 74 75 and older Selected Chronic Health Conditions Causing Limitation of Activity Among adults by Age: 1998 to 2000 (Number of people with limitation of activity caused by selected chronic health conditions per 1,000 population) Arthritis/other musculoskeletal Heart/other circulatory Vision/hearing Fractures/ joint injury Diabetes Mental illness 22.0 73.2 117.8 193.1 5.4 45.5 110.8 170.9 4.2 13.8 31.2 82.5 6.8 15.9 25.4 48.6 2.6 18.5 38.4 42.5 10.4 18.6 11.4 10.7 FIGURE 2-7 Chronic health conditions causing activity limitations by age group. (From He W, Sengupta M, Velkoff VA, Debarros, KA: U.S. Census Bureau population reports, P23–209, 651 in the United States: 2005. Washington, DC: U.S. Government Printing Office, 2005.)
24 CHAPTER 2 Implications of an Aging Population for Rehabilitation hed ephochPpknawdgcfmdsk and the biyo a bathroom are especially important elements in the as effects of co se on fun The'ahb ability c n tohcCploratig one comorbidity that has a documented negative effect time period,to move safely on and off the receptacle,and o function is obesity. Physical therapists working to perform self-hygiene tasks with other ssion: can have a major impac nta of Daily Living. 4 exami thnd ADL ntial to liv health. to use public transportation or drive a car.For some in FUNCTION appropr che to nvestigate th Physical Function and Disability Relationship between ADLs and IADLs.Most older Physical,psychological,and social function are all di mension function th ure n both between AD ADI Thus,a home-care physical therapist working with a decline is influenced by a host of biological,psychologi- pital afte task and acti la not only ties would serve as the first goals of intervention.If the tasks th patient was independent in basic ADL upon to meet throug te pnys IADL proach to functional assessment of an older adult in- which supports a person's ability to live independently in account what is an of care,as the pat that person sp the physi ity,which includes transfers and ambulation: Paaoeooeanneacgmsg such as hon care and personal hygiene (ADls):more complex dult's ing in the community vn as instrumental ADLs (IADI s):wor recre o山 in the comr munity. Mobility.A prin sly it has heer performing a physical functional ass ment of any adult did not need to or want to work,based on data trends individual is to identif any anctional limitations in mo have ended in t th 1980 Changes in can rang om t to mov epen gulations have num level surfaces within the home stair elimbin ne uneven terrain,and walking for longer distances in the community.Mobility is a component of ADLs,work, adults who want to,or nee Basic Activities of Daily Living.Basic ADLs include nstitutionalized individuals older than age 65 y all of the fundamental tasks and activities necessary for are still counted in the workforce.Specifically,34.4%of survival,hygiene,and self-care within the home.A typical the men and 24.2%of the women age 65 to 69 vears
24 CHAPTER 2 Implications of an Aging Population for Rehabilitation with a stroke, who also has degenerative changes in the foot and low tolerance for stressful activity secondary to angina with exertion, can present a particular challenge to the geriatric physical therapist’s knowledge and skill. Although there is an emerging body of knowledge on the effects of disease on function, less is known about the effects of coexistent disease on function. Older adults vary a great deal in the degree to which their chronic comorbidity affects their functional capacities. However, one comorbidity that has a documented negative effect on function is obesity.23-26 Physical therapists working with other health professionals can have a major impact on functional decline by applying their evidence base in exercise and physical activity to this threat to public health. FUNCTION Physical Function and Disability Physical, psychological, and social function are all dimensions of function that are included in the measurement of a person’s overall health status. Physical therapists address issues of physical function. In general, independent physical function declines with age, and this decline is influenced by a host of biological, psychological, and social factors. Function is not a static phenomenon and individual transitions in functional status are more the norm than the exception. Function is also a sociological phenomenon. Functional assessment does not only measure the individual’s abilities to perform tasks that are personally meaningful to the individual, but it also measures performance essential to meeting social expectations of what is “normal” functioning for an adult. It is therefore necessary that the overall approach to functional assessment of an older adult include items that take into account what is “normal” in that person’s social and cultural sphere. Physical functional activities can be subdivided into five areas: mobility, which includes transfers and ambulation; basic selfcare and personal hygiene (ADLs); more complex activities essential to an adult’s living in the community, known as instrumental ADLs (IADLs); work; and recreation. Mobility. A primary concern of physical therapists in performing a physical functional assessment of any adult individual is to identify any functional limitations in mobility that can range from the ability to move independently in bed, transfer from bed to chair, ambulation on level surfaces within the home, stair climbing, negotiating uneven terrain, and walking for longer distances in the community. Mobility is a component of ADLs, work, and recreational activities. Activities of Daily Living Basic Activities of Daily Living. Basic ADLs include all of the fundamental tasks and activities necessary for survival, hygiene, and self-care within the home. A typical ADL battery, which may be administered by a physical therapist alone or cooperatively with other health professionals, covers eating, bathing, grooming, dressing, bed mobility, and transfers. Incontinence and the ability to use a bathroom are especially important elements in the assessment of physical function in some older individuals. The ability of an adult in three aspects of independent toileting function may require exploration of specific task accomplishment: to get to the bathroom in an appropriate time period, to move safely on and off the receptacle, and to perform self-hygiene tasks. Instrumental Activities of Daily Living. An examination and evaluation of IADLs addresses multiple areas that are essential to living independently as an adult: cooking, shopping, washing, housekeeping, and ability to use public transportation or drive a car. For some individuals, it may also be appropriate to investigate the ability to perform home chores such as shoveling snow or yardwork. Relationship between ADLs and IADLs. Most older adults living in the community are generally independent in both ADLs and IADLs (Figure 2-8). The relationship between ADL and IADL is generally hierarchical; that is, limitations in ADL usually predict limitations in IADL. Thus, a home-care physical therapist working with a patient recently returning home from an acute care hospital after a hip fracture would first explore the individual’s ability to do the tasks and activities encompassed by basic ADL, such as transfers, ambulation, and toileting. If deficits were found, independence in these activities would serve as the first goals of intervention. If the patient was independent in basic ADL upon initial examination, or became independent through the physical therapist’s intervention, the therapist would then examine the older person’s limitations in performing IADL, which supports a person’s ability to live independently in the community. As part of the plan of care, as the patient progresses to greater levels of independence, the physical therapist will play an important role in identifying the patient’s needs for formal caregivers, such as homemakers and home health aides, and in teaching families how to manage a person’s limitations well enough so that the individual may continue to reside in the community. Work. One measure of adult competence is employment. Previously, it has been assumed that older adults did not need to or want to work, based on data trends that appear to have ended in the 1980s.4 Changes in federal regulations have raised the minimum age at which individuals may receive full Social Security benefits and mandatory retirement at a specific age for most occupations is not typically permitted. Therefore, older adults who want to, or need to, remain in the workforce may do so if they are physically able to perform the tasks of their employment. A substantial proportion of civilian noninstitutionalized individuals older than age 65 years are still counted in the workforce.4 Specifically, 34.4% of the men and 24.2% of the women age 65 to 69 years
CHAPTER 2 Implications of an Aging Population for Rehabilitation 25 work would be.Interestingly recent studies of the abilir to perform these kinds of physical functional tasks indi 70 Canid ant d erence b 49 13 12 IADLs only Clearly,more older men and women toda 30 sports that 20 1 to 2 ADL e eational sports as older adults ment of recreational activities,however,is not limited to 10 8A8 sports.Many adults enjoy dancing and degree o. 199 99 2001 200 require a thavely high r play g chess.require a certain s t physical ability in the hand and upper extremity and therefore may be functional measures of the outcomes of ntervention r some patients on,shop Heath and Health Care Utilization of Services.Functional deficits are impor utilization of services ing in a fac ents in ho health care nd to 2008 ncy Forum on Agng Washington,DC:US Govemment,March200 be women,white,widowed,between the ages of 75 and 84 years,and living in a private residence.Almost half of these receive care from family members were labor force participants in 2006.The reduction among women age 70 years or older (7.1%)in ing home utilization is generally on the decline.probably comparison to their male peers (24.2%).Overall,the attributable to emerging alternative care options such as rates of labo ion for olde Americans assisted living.Currently,it appears that any racial di nave grown men anc a muc inghome usage that may h us tional changes in roles and societal expectations for and older.The ast maiority of women working outside the home,particularly during nursing home residents need assistance with three or the pastour decades. an bsic to work or basic ADL tinct rac has participation against the general conditions of work itself Is the individual working the anticipated number of hours mod in any respect the job be rgrams such as M re or proportion out of private insurance.adulrs poverty or near poverty have the worst health status examine an individual's ith cate (0)and also incur the greatest healthcar hty:(1)w t Trer d Er in the demo hic characteristics of the U.S.p (5)stooping,crouching,or kneeling;(6)reaching up over head;(7)r
CHAPTER 2 Implications of an Aging Population for Rehabilitation 25 or carrying 25 pounds. Using these data on “advanced” mobility, one can infer what an individual’s capacity to work would be. Interestingly, recent studies of the ability to perform these kinds of physical functional tasks indicated increasing disability with every decade and a significant difference between men and women that persisted in every age group (Figure 2-9).4 Recreation. Recreational activities are no less important than work to maintain a sense of well-being. Clearly, more older men and women today are maintaining interests in recreational sports that they developed earlier in life. Others are discovering the pleasures of recreational sports as older adults. Functional assessment of recreational activities, however, is not limited to sports. Many adults enjoy dancing and gardening, which require a relatively high degree of balance, flexibility, and strength. Even sedentary activities, such as stamp collecting or playing chess, require a certain degree of physical ability in the hand and upper extremity and therefore may be functional measures of the outcomes of intervention for some patients. Heath and Health Care Utilization of Services. Functional deficits are important markers for increased utilization of services, especially with the use of formal services such as home health care. Older patients in home health care tend to be women, white, widowed, between the ages of 75 and 84 years, and living in a private residence. Almost half of these receive care from family members.4 In contrast, nursing home residents are likely to be women, especially those older than age 85 years.6 Nursing home utilization is generally on the decline, probably attributable to emerging alternative care options such as assisted living. Currently, it appears that any racial disparities in nursing home usage that may have previously existed are disappearing especially among nursing home residents aged 85 years and older.6 The vast majority of nursing home residents need assistance with three or more basic ADLs, particularly bathing and dressing.6 A distinct racial disparity in functional status has been documented among black nursing home residents, who are more likely to be functionally limited in basic ADLs than their nonblack peers.28 The majority portion of health care expenditures is paid by public programs such as Medicare or Medicaid.6 Yet nearly 20% is paid out of pocket and a smaller proportion out of private insurance. Older adults in poverty or near poverty have the worst health status (Figure 2-10) and also incur the greatest health care costs.6,29 Current Trends and Future Possibilities. Changes in the demographic characteristics of the U.S. population represent a critical challenge to geriatric physical therapists. Older adults are expected to live longer than ever before, but the quality of their lives in these added years 1992 1997 2001 2005 5 to 6 ADLs 3 to 4 ADLs 1 to 2 ADLs IADLs only Facility 100 90 80 70 60 50 40 30 20 10 0 Percent 14 20 49 4 6 6 13 17 43 13 44 5 3 5 17 5 3 5 12 42 18 5 3 4 Note: The Medicare Current Beneficiary Survey has replaced the National Long Term Care Survey as the data source for this indicator. Consequently, the measurement of functional limitations (previously called disability) has changed from previous editions of Older Americans. ADL limitations refer to difficulty performing (or inability to perform for a health reason) one or more of the following tasks: bathing, dressing, eating, getting in/out of chairs, walking, or using the toilet. IADL limitations refer to difficulty performing (or inability to perform for a health reason) one or more of the following tasks: using the telephone, light housework, heavy housework, meal preparation, shopping, or managing money. Rates are age adjusted using the 2000 standard population. Data for 1992 and 2001 do not sum to the totals because of rounding. Reference: These data refer to Medicare enrollees. Source: Centers for Medicare and Medicaid Services, Medicare Current Beneficiary Survey. FIGURE 2-8 Percentage of Medicare enrollees with limitations in activities of daily living (ADLs) or instrumental ADLs (IADLs) or residing in a facility. (From Federal Interagency Forum on Aging-Related Statistics: Older Americans 2008: key indicators of well-being. Washington, DC: U.S. Government Printing Office, March 2008.) were labor force participants in 2006. There is a striking reduction among women age 70 years or older (7.1%) in comparison to their male peers (24.2%). Overall, the rates of labor force participation for older Americans have grown for both men and women, with a much steeper increase for women most likely due to generational changes in roles and societal expectations for women working outside the home, particularly during the past four decades.4 Physical limitations impacting one’s ability to work can be examined by comparing an individual’s work participation against the general conditions of work itself: Is the individual working the anticipated number of hours each week? Have the requirements of the job been modified in any respect to allow the individual to work? Does the quantity or quality of work completed meet the anticipated standard of performance? Another approach to assessing work performance, first described by Nagi,27 is to examine an individual’s ability to perform 10 particular physical tasks associated with work disability: (1) walking up 10 steps without resting; (2) walking a quarter of a mile; (3) sitting for 2 hours; (4) standing for 2 hours; (5) stooping, crouching, or kneeling; (6) reaching up overhead; (7) reaching out to shake hands; (8) grasping with fingers; (9) lifting or carrying 10 pounds; and (10) lifting
26 CHAPTER 2 Implications of an Aging Population for Rehabilitation Perepe8ocrnrmy9iole2e65ndaceg9hanr2obi9 ☐1991 ■2005 Men Women 100 90 80 80 70 70 50 50 40 532 Note:Rates tor1991 FIGURE 2-9 Perc Poverty status1 Poor Near poor Not poor %confidence interval decline with advanced age.Function deficits are the ex pected outcomes of disease;in turn,functional limita- tions predictnFuture research must blish the of,and cal th nmust est of di old age REFERENCES To enbance this text and add value for the reader.all 55-64 65-74 75-84 85an 五 hat accompanies this text book Intervewuvey04-007 FIGURE 2-10 Per age o
26 CHAPTER 2 Implications of an Aging Population for Rehabilitation is still a matter of conjecture. Aging with multiple diseases further aggravates a propensity toward physical decline with advanced age. Function deficits are the expected outcomes of disease; in turn, functional limitations predict increased utilization of services, further morbidity, and death. Future research must establish the ability of physical therapy to delay the onset of disease and disability and to prolong optimal function well into old age. REFERENCES To enhance this text and add value for the reader, all references are included on the companion Evolve site that accompanies this text book. The reader can view the reference source and access it online whenever possible. There are a total of 29 cited references and other general references for this chapter. 100 90 80 70 60 50 40 30 20 10 0 Percent Men 8 10 3 3 14 9 15 2 1 8 19 19 Stoop/ kneel Reach over head Write Walk 2-3 blocks Lift 10 lbs. Any of these five Stoop/ kneel Reach over head Write Walk 2-3 blocks Lift 10 lbs. Any of these five 100 90 80 70 60 50 40 30 20 10 0 Percent Women 15 18 3 2 6 5 23 23 18 16 32 32 Percentage of Medicare enrollees age 65 and older who are unable to perform certain physical functions, by sex, 1991 and 2005 1991 2005 Note: Rates for 1991 are age adjusted to the 2005 population. Reference population: These data refer to Medicare enrollees. Source: Centers for Medicare and Medicaid Services, Medicare Current Beneficiary Survey. FIGURE 2-9 Percentage of Medicare enrollees who cannot perform selected physical tasks by sex. (From Federal Interagency Forum on Aging-Related Statistics: Older Americans 2008: key indicators of well-being. Washington, DC: U.S. Government Printing Office, March 2008.) 60 50 40 30 20 10 0 Percent 55-64 65-74 75-84 85 and older Poverty status1 Not poor 1 Defined as follows; poor (family incomes below poverty threshold); near poor (family incomes 100% to less than 200% of poverty threshold); and not poor ( family incomes 200% of poverty threshold or greater). Note: Data are based on household interviews of a sample of the civilian noninstitutionalized population. Data source: CDC/NCHS, National Health Interview Survey, 2004-2007. Poor Near poor 95% confidence interval FIGURE 2-10 Percentage of adults age 55 years and older in fair or poor health by age group and poverty status. (From Schoenborn CA, Heyman KM: Health characteristics of adults aged 55 years and over: United States, 2004–2007. National health statistic reports, no. 16. Hyattsville, MD: National Center for Health Statistics, 2009.)