Elsevier

Archives of Gerontology and Geriatrics

Volume 65, July–August 2016, Pages 239-247
Archives of Gerontology and Geriatrics

Protocol paper
Risk factors for functional decline in a population aged 75 years and older without total dependence: A one-year follow-up

https://doi.org/10.1016/j.archger.2016.04.002Get rights and content

Highlights

  • Study of a representative sample of non-dependent >75 year-olds at primary care.

  • The Short There are important gaps in the tools to deal with frailty in primary care.

  • Physical Performance Battery is useful to identify elderly people at risk.

  • Suitable management of hospitalization could protect the elderly’s functional status.

Abstract

Objectives

estimation of functional loss incidence and identification of risk factors associated with new disability onset in people aged 75 and older without severe dependence in a rural primary care setting.

Patients and method

Prospective cohort study of a representative sample of people aged 75 years or older without severe dependence (Barthel Index > 20 and Lawton Index > 1) at a primary care center, with a 12-month follow-up. The baseline geriatric assessment recorded activities of daily living (ADL), sociodemographic information, numbers of drugs prescribed, previous hospital admissions and falls, cognitive function, hearing and visual capacity, body mass index, blood pressure, and the Short Physical Performance Battery to evaluate lower limb function. ADL was re-assessed after 12 months, defining functional loss as a fall of ≥10 points on the Barthel Index and/or ≥2 instrumental activities of the Lawton Index. Bivariate and multivariate analyses using logistic regression models were conducted to identify factors independently associated with functional loss.

Results

Mean age was 81.7 years, 58.7% of patients were men, and 23.4% presented functional loss at the 12-month follow-up. Variables identified as independent predictors of functional loss were hospital admissions (aOR 3.92; 95%CI: 1.35–11.39), cognitive impairment (aOR 2.60; 95%CI: 1.39–4.92) and lower limbs functional limitation (aOR 2.01; 95%CI: 1.02–3.97).

Conclusions

Our results support the use of performance batteries in primary care for identifying elderly persons at risk of functional decline; and they also highlight the relevance of appropriate management of hospital admissions and planned discharges in order to preserve patients’ functional status.

Introduction

European countries present an increasing ageing population. In early 2010, the amount of people over-65 years old was a quarter of those at working age (15–64 years). Spain is among the countries with the highest life expectancies in Europe (GHO, 2014). Over the past decade, life expectancy at age 65 has increased among both women (from 21.0 to 22.7 years) and men (from 16.9 to 18.5 years) (EHLEIS, 2013). Estimates for 2021 indicate that the over-65 will equal 30% of individuals at working age in Spain, and that one in three of those will be aged 80 or more (IMSERSO, 2004).

Functional decline has been broadly defined as the loss of ability to independently carry out activities of daily living (ADL) (Covinsky, Justice, Rosenthal, Palmer, & Landefeld, 1997). In developed societies, around 20% of people aged 70 years or older, and 50% aged 85 and older present disabilities in basic ADL (Heikkien, 2003). The annual rate of new disability in people aged 75 and older is estimated around 12% (Hebert, Brayne, & Spiegelhalter, 1997). The increase in disability and dependence is not only explained by the inversion of the population pyramid, but also by other factors that are modifiable, and therefore target of intervention. The modifiable risk factors associated with new disability described in the literature are (Beaton, McEvoy, & Grimmer, 2015; Stuck et al., 1999; Tas, Verhagen, Bierma-Zeinstra, Odding, & Koes, 2007; Vermeulen, Neyens, van Rossum, Spreeuwenberg, & de Witte, 2011): prior functional status measured by ADL, functional limitation of the lower limbs, loss of upper body strength, cognitive impairment, depression, comorbidity, polypharmacy, thinness/emaciation or obesity, reduced social contact, physical inactivity and visual impairment.

Epidemiological studies in the elderly, traditionally focused on severe disability, changed the focus to healthy ageing towards the end of the last century, now studying samples of relatively healthy, independent older people (Berkman et al., 1993, Fried et al., 2001, Rockwood et al., 2005). These studies suppose an attempt to identify the subgroup of elderly people who maintain an unstable independence and who are in risk of functional loss. Investing efforts in health promotion to avoid disability continues being relevant at these ages, considering that people with good functional status at age 70 have higher longevity with better health, without generating higher healthcare costs (Lubitz, Cai, Kramarow, & Lentzner, 2003).

Frail older people have an increased risk for adverse health outcomes, such as disability, hospitalization, institutionalization and mortality (Ferrucci et al., 2004). Frailty has been defined as a geriatric syndrome characterized by a relevant reduction of physiologic reserves increasing the person’s vulnerability to endogenus and exogenus stressors, an reducing the person’s ability to maintain a homeostatic balance (Morley et al., 2013). Nowadays, despite the consensus on the definition of frailty, it is still not clear how to operationalize it. Two approaches predominate: either using complex multidimensional indices based on accumulated health deficits, as in two Canadian studies with 36 (Song, Mitnitski, & Rockwood, 2010) and 70 variables (Rockwood et al., 2005); or the frailty phenotype proposed by Fried et al. (2001) based on five criteria (walking speed, grip strength, self-reported activity levels, exhaustion and unintended weight loss). But even this latest 5-criteria approach presented difficulties in clinical practice as the hand grip strength is not frequently assessed.

Primary care is the most appropriate setting to detect and take care of frailty. However, the identification of the frailty syndrome is still too complex to be considered clinically friendly (Lacas & Rockwood, 2012; Rouge Bugat, Cestac, Oustric, Vellas, & Nourhashemi, 2012). Few measures have been validated in a primary healthcare setting, and not many studies recruit patients directly in primary care consultations (Pialoux, Goyard, & Lesourd, 2012). General practitioners need easy tools to identify frailty. The identification of modifiable risk factors of functional loss would provide frailty markers for the clinical setting and may help to define strategies to delay the onset and progression of disability.

The aim of the present study was to estimate the incidence of functional loss and to identify the risk factors associated with the onset of new disability in people aged 75 and over without severe dependence in a rural primary care setting.

Section snippets

Design

Prospective cohort study of a representative sample of people aged 75 years or older without severe dependence treated at the Primary Care Center El Remei (Vic, province of Barcelona, Spain), with a follow-up of 12 months. Inclusion criteria were Barthel index > 20 and Lawton-Brody index > 1. Exclusion criteria were: participation in any homecare assistance program, terminal illness with prognosis of less than six months of life, presence of a severe problem in the days prior to the assessment,

Results

Of the 315 participants in the baseline evaluation, 8 with the minimum Lawton-Brody Index were excluded because they could not decrease and therefore develop a new disability according to our definition. At the follow-up, 12 months after baseline, 14 subjects had died (4.6%), 32 could not be located (10.4%), and nine (2.9%) dropped out. Finally, 252 subjects (82.1%) with a mean age of 81.7 years (SD 4.6) were reassessed.

Compared with the final study sample, the 41 subjects lost to follow-up

Discussion

Globally, 23.4% of the elderly subjects aged 75 years or older without severe dependence had developed a new disability at the 12-month follow-up. Hospital admissions, cognitive impairment, and lower limb functional disability were the independent risk factors of disability identified in our study: neither age, nor socio-demographic factors (such as gender, educational level, marital status or living situation), nor common geriatric assessment indicators (such as the number of drugs, Barthel

Conclusions

Although primary care is the most appropriate setting to take care of frailty, there are important gaps in the instruments to measure it. Our results suggest that performance tests may be useful for identifying elderly persons at risk of functional decline at primary care, and highlight the importance of an appropriate management of hospital admissions and planned discharges in order to preserve patients’ functional status in population aged 75 years and older.

Conflicts of interest

The authors have no conflicts of interest to declare.

Funding

Health Research Fund (PI042370) and the European Regional Development Fund (FEDER).

III Research Grant of Osona promoted by the Foundation of the Medical and Health Sciences Academy of Catalonia and the Balearics, the Medical Science Group of Osona and the Osona Branch of the Catalan Society of Family and Community Medicine.

Non of the funding organizations had any influence on study design, the collection, analysis, and interpretation of data, on the writing of the manuscript and on the decision

Authors’ contributions

A. Arnau and J. Espaulella designed the study and supervised all aspects of its production. M. Serrarols and J. Canudas were responsible for the geriatric assessment and data extraction. A. Arnau performed the statistical analysis of the data. A. Arnau, J. Espaulella, M. Ferrer and F. Formiga interpreted the findings and contributed to the writing of the first draft. All authors contributed ideas and reviewed drafts of the manuscript. All authors approved the final version. A. Arnau is the

Acknowledgements

This study was possible thanks to funding from the III Research Grant of Osona promoted by the Foundation of the Medical and Health Sciences Academy of Catalonia and the Balearics, the Medical Science Group of Osona and the Osona Branch of the Catalan Society of Family and Community Medicine and a grant from the Fund for Health Research of Spain (PI042370) and the European Regional Development Fund (FEDER).

We thank Michael Maudsley of the Language Service of the University of Barcelona and

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