Activities Of Daily Living Difficulties Research Articles

Daily activities and hand function in women with scleroderma

Objective: To give a detailed description of hand function and the ability to perform daily activities among patients with systemic sclerosis.Methods: Thirty patients with scleroderma answered a self‐administered activities of daily living (ADL) questionnaire. Hand function was estimated with respect to hand mobility, dexterity, and grip force. Perceived symptoms were reported on a visual analogue scale (VAS), and skin thickness was assessed by means of the modified Rodnan skin score.Results: Finger flexion and extension were the most impaired aspects of hand mobility. Dexterity was on average reduced to 68–80%, and grip force to 46–65% compared with values for healthy persons. The predominant self‐perceived problem was Raynaud's phenomenon, whereas pitting scars/ulcers were perceived as the least problem. Activities building on hand and arm function were harder to perform than activities depending on lower limb function. Raynaud's phenomenon, stiffness, grip force, and dexterity were factors with the strongest associations with ADL difficulties. Assistive devices and alternative working methods improved ADL ability.Conclusion: Impaired hand function was related to ADL difficulties and the use of assistive devices improved ADL. This emphasizes the importance of treatments that improve hand function and of testing ergonomic tools.

Outcomes after stroke: Basic and instrumental activities of daily living, community reintegration and generic health status

This study describes the discharge destination, basic and instrumental activities of daily living (ADL), community reintegration and generic health status of people after stroke, and explored whether sociodemographic and clinical characteristics were associated with these outcomes. Participants were 51 people, with an initial stroke, admitted to an acute hospital and discharged to the community. Admission and discharge data were obtained by chart review. Follow‐up status was determined by telephone interview using the Modified Barthel Index, the Assessment of Living Skills and Resources, the Reintegration to Normal Living Index, and the Short‐Form Health Survey (SF‐36). At follow up, 57% of participants were independent in basic ADL, 84% had a low risk of experiencing instrumental ADL difficulties, most had few concerns with community reintegration, and SF‐36 physical functioning and vitality scores were lower than normative values. At follow up, poorer discharge basic ADL status was associated with poorer instrumental ADL and community reintegration status, and older participants had poorer instrumental ADL, community reintegration and physical functioning. Occupational therapists need to consider these outcomes when planning inpatient and post‐discharge intervention for people after stroke.

ALBERT ET AL. RESPOND

We appreciate the comments of Crews and Smith, who suggest that disability is best understood using the World Health Organization’s International Classification of Functioning, Disability and Health (ICF).1 This model stresses “activity limitation” and “participation restriction,” rather than disability, and explicitly includes environmental factors in assessing the impact of health conditions. Crews and Smith argue that this model helps “avoid any suggestion that disability is a negative, undesirable end state, and, by implication, a circumstance less amenable to public health intervention.” Our model (which we could not present fully in our August 2002 editorial) differs from the ICF approach in asserting a strict temporal and causal sequence. Pathology (e.g., sarcopenia) leads first to impairment (e.g., lower-extremity weakness evident in manual muscle testing); when lower-extremity weakness crosses some threshold, functional limitation becomes evident, measurable perhaps in gait speeds below age- and gender-appropriate norms. When gait speed, in turn, drops below the minimum speed required to cross at a signaled intersection, a person is likely to report difficulty or a need for help crossing the street, that is, disability.2 In our editorial, we suggested that environmental factors affect this sequence. For example, changing the timing of traffic lights or even changing the time one goes out to do errands might prevent functional limitation from becoming disability. Rehabilitation or exercise to promote leg strength, or use of a motorized scooter, could break the link between impairment and functional limitation. One advantage of the model we propose is the solid tradition of measurement behind it. For example, even in people who do not report mobility problems, weakness in the lower extremities predicts incident disability in the activities of daily living (ADL).3 People who do not report difficulty in ADL but report they have changed the way they perform these tasks have slower gait speeds and poorer grip strength.4 This approach thus identifies key points for intervention in the pathways to disability. By making disability an outcome, does our approach minimize the experience of people who use personal assistance or assistive technologies to perform daily activities? We do not think so. We recently interviewed a 92-year-old woman who used a walker, required personal assistance for ADL 24 hours a day, and took 10 different medicines for 6 chronic conditions. Her ADL dependence was complete, yet she scored quite high on measures of activity and social participation, and she considered every day quite satisfying and interesting. By any account this is successful aging,5 yet she also sought ways to reduce her ADL dependency. For understanding her need for assistance, the etiology of this need, and potential points for intervention, we would argue that it is useful to model disability explicitly, even if it is narrowly defined. Finally, we wholeheartedly agree that “aging and disability need to be modeled together.” This may be the key challenge for public health and the second 50 years of life.

Dissatisfaction with medical services among medicare beneficiaries with disabilities

Jha A, Patrick DL, MacLehose RF, Doctor JN, Chan L. Dissatisfaction with medical services among Medicare beneficiaries with disabilities. Arch Phys Med Rehabil 2002;83:1335-41. Objective: To test the hypothesis that Medicare beneficiaries who have difficulties performing activities of daily living (ADLs) are more likely to report dissatisfaction with their health care than those without ADL difficulties. Design: Cross-sectional study. Setting: Sample from the 1998 Medicare Current Beneficiaries Survey. Participants: A population-based sample (N=19,650) of noninstitutionalized Medicare beneficiaries. Interventions: Not applicable. Main Outcome Measures: Satisfaction with overall quality and 9 specific aspects of medical services received in the last year. Results: After adjusting for sociodemographic, behavioral, and system characteristics and compared with those without ADL difficulties, Medicare enrollees were more likely to report dissatisfaction with the overall quality of their health care as their number of activity restrictions increased (1–2 ADLs: odds ratio [OR]=1.5; 95% confidence interval [CI], 1.2–2.0; 3–4 ADLs: OR=1.7; 95% CI, 1.2–2.4; 5–6 ADLs: OR=1.9; 95% CI, 1.4–2.8). Analysis of satisfaction with the 9 specific aspects of care yielded similar results. Conclusion: Disability is a significant independent risk factor for dissatisfaction with health care in the Medicare population. Efforts should be made to identify individuals with ADL difficulties and to improve their ease and convenience of getting to a doctor, the availability of care off hours, the access to specialists, and the follow-up care received. © 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Housing Changes and Moves into Supportive Housing Among Adults with Disabilities

About one fifth of the adult population with disabilities living in the community moved during a 12-to 24-month period between 1994 and 1996. This article examines the extent to which the ability to perform activities of daily living (ADL) and instrumental activities of daily living (IADL) was associated with these moves. Data are from the 1994-1995 National Health Interview Survey (NHIS), the 1994-1995 Supplement on Disability, and the Disability Followback Survey. Analyses controlled for gender, income, living alone, racelethnicity, health status, and selected mental conditions. Decreased IADL ability had little association with the likelihood of moving, whereas increased difficulty with the ADL tasks of bathing, dressing, eating, and toileting generally increased this likelihood. These effects were more evident among those age 65+ than among those ages 18 to 64, and more common among house than apartment residents. For older persons, increases in ADL difficulties were associated with moves into supportive housing.

Explaining the Role of Sex on Disability

There is no clear consensus about how sex influences prevalent disability and through what mechanisms. We investigated whether sex had a direct independent effect on disability or whether sex had an interactive effect on the relationship between chronic diseases/conditions and disability, and whether these effects differed in middle-aged versus older adults. We used baseline data from two nationally representative health interview surveys, the Health and Retirement Study (HRS) and the Study of Asset and Health Dynamics Among the Oldest Old (AHEAD), and disability and covariate measures that were nearly identical in both surveys. Logistic regression models tested the contributions of diseases, impairments, and demographic and social characteristics on difficulties with prevalent activities of daily living (ADLs), mobility, and strength. Models demonstrated no direct sex effect for ADL disability in either age group after adjusting for key covariates. However, sex did exert an indirect effect on ADL disability in older adults via musculoskeletal conditions and depressive symptoms. In contrast, female sex remained strongly associated with mobility and strength disability in both age groups, net of covariates. Major interactions were also significant, including a female sex/body mass index (BMI) interaction for mobility difficulty and several sex-disease interactions for strength disability in the middle-aged group. The effect of sex on ADL difficulty is largely explained by social and health-related covariates in middle-aged and older adults. In contrast, the independent association of female sex with decreased strength and mobility in both groups cannot be explained by our models' social or health-related variables. In addition, the positive association of BMI with mobility difficulty is significantly worse for women than for men.

Unmet Need for Personal Assistance With Activities of Daily Living Among Older Adults

This study examined the prevalence, correlates, and negative consequences of unmet need for personal assistance with activities of daily living (ADLs) among older adults. The authors analyzed cross-sectional data from the 1994 National Health Interview Survey's Supplement on Aging. Data were weighted to be representative of the noninstitutionalized population aged 70 years and older. Overall, 20.7% of those needing help to perform 1 or more ADLs (an estimated 629,000 persons) reported receiving inadequate assistance; for individual ADLs, the prevalence of unmet need ranged from 10.2% (eating) to 20.1% (transferring). The likelihood of having 1 or more unmet needs was associated with lower household income, multiple ADL difficulties, and living alone. Nearly half of those with unmet needs reported experiencing a negative consequence (e.g., unable to eat when hungry) as a result of their unmet need. Greater, targeted efforts are needed to reduce the prevalence and consequences of unmet need for ADL assistance in elderly persons.

The Disablement Process in Very Late Life: A Study of the Oldest-Old in Sweden

The study examines physical and functional health problems and their relationship to the activity of daily living (ADL) disability experience of a cross-section of Swedish men and women aged over 80 years (N = 203). Using a model of disablement, the relationships among disability variables were simultaneously explored. Results confirmed relatively high rates of disability in this age group, with 36% of respondents having some basic ADL difficulty. Functional impairments (vision and grip strength) and functional limitations (upper and lower body limitations and cognition) were strongly related to disability, with functional limitations being a main driving force for disability. The role of psychosocial variables (depression, subjective health, and social integration) was explored through subsequent model testing. Results showed depression, subjective health, and social integration to potentially mediate the influence of risk factors, impairments, and limitations in the model. The study suggests that modifying psychosocial experiences can greatly affect the disability experience.

Factors associated with thoracic spinal cord injury, lesion level and rotator cuff disorders.

The study was concerned with the secondary functional compromise persons with long-term paraplegia contend with, that has been shown to be associated with wheelchair use. Of particular interest was the relationship between the level of thoracic spinal cord injury (SCI) and factors predisposing to rotator cuff disorders (RCD), one of the most common upper extremity musculoskeletal complications linked with long-term SCI. Disorders of these peri-articular structures have previously been associated with impaired trunk postural control and abnormal muscle strength ratios in both able-bodied groups and in paraplegic athletes. Despite their neurologically intact shoulder joint musculature, high-level and low-level paraplegics have different degrees of trunk and pelvic stability available to them during activities of daily living (ADL). This fundamental functional anatomical difference between high-level and low-level paraplegics had not previously been related to the diagnosis of RCD in a non-athletic long-term paraplegic population. A descriptive cross sectional study was undertaken to demonstrate the differences in the prevalence of clinically diagnosed RCD in a high-level (n=22) and a low-level (n=20) group of persons with long-term paraplegia. Any perceived differences were then related to the functional anatomical variations between the two groups. Inferences were made based on factors predisposing to RCD known to exist among both able-bodied and paraplegic athletes. The 42 subjects completed the Wheelchair User's Shoulder Pain Index (WUSPI) to establish the presence or absence of shoulder pain and the Musculoskeletal Function Assessment (MFA) instrument to determine differences in functional ability and perceived degree of difficulty within five categories of ADL. Each participant underwent a clinical examination using validated provocative clinical tests and isometric muscle strength ratio testing. There was a higher prevalence of RCD in the high-level group (P=0.009) which correlated with decreased trunk control (P=0.009). Differences in ability to perform functional tasks were not shown to be greater in the high-level group, although there was a higher degree of perceived difficulty in ADL. Muscle strength imbalances between the shoulder adductors and abductors were shown to be greater in the high-level group. The results of this study suggest that the functional anatomical differences that exist within paraplegia contribute to the propensity of high-level paraplegic persons to suffer from RCD. These findings send a clear message to service-providers that greater acknowledgement of the differences in trunk postural control specific to the level of thoracic SCI is required. This may have implications for the prescription of wheelchairs, assistive devices and instruction for alternative ADL techniques to this specific population.

Psychiatric disorder and dysfunction in the UK National Survey of Psychiatric Morbidity

Psychiatric symptoms are wide-spread in the general population, but have little effect on performance. Deficits in performance and psychiatric symptoms may be the end point of processes common to both, or they may be caused by quite different factors. In this paper we examine the epidemiological distribution of psychiatric symptoms and performance deficits, as indicated by difficulties in activities of daily living (ADL). We hypothesised that ADL difficulties are partly independent of psychiatric symptoms, and that this is reflected in a different demographic distribution. The household component of the National Surveys of Psychiatric Morbidity was based on a sample of around ten thousand subjects selected at random from the population of Great Britain. Psychiatric symptoms were elicited by lay interviewers using the revised Clinical Interview Schedule. Performance was assessed by asking about difficulties experienced in performing seven types of everyday activity. In this paper, our chosen variables were overall symptom and ADL deficit scores, and these were related to standard demographic variables. There were significant differences in the epidemiological distribution of psychiatric symptoms and ADL difficulties. In particular, men experienced more ADL difficulties at a given symptom level than women. There were also differences in relation to social class, employment status, marital status, ethnic group and age. ADL deficits and psychiatric symptoms are related in the general population, and this probably represents common factors in their origin. However, discrepancies in the social distribution of these phenomena suggest there are also aetiological differences. These do not appear to be the result of the impact of physical illness on activities of daily living. Our results emphasise that ADL difficulties should be studied separately, particularly in investigations of treatment seeking.

Activities of daily living. Old-fashioned or still useful?

1 The Index of Activities of Daily Living (ADL) is used by many nurses to assess function in older adults, but there is debate regarding the scoring, wording of questions, and validity in diverse populations. 2 Older adults may give inaccurate answers to ADL questions because they misunderstand the questions, have personal reasons for underreporting or overreporting difficulty in ADL, or fail to recognize difficulty because they have adapted to changes in function. 3 Physical performance tests, especially of the lower extremities, may be an alternative method of assessing function, especially in high-functioning older adults who report no difficulty in ADL.

Characteristics and behaviours associated with difficulty in performing activities of daily living among older New Zealand women

Purpose: The objective of this cross-sectional study was to determine the prevalence of self-reported difficulty in perfoming activities of daily living (ADLs) and the associated characteristics and behaviours among older women in Auckland, New Zealand. Methods: A sample of 569 community dwelling women aged 65 years and older were studied. Logistic regression was used to calculate odds ratios and 95% confidence intervals for the association of participant characteristics and behaviours with reported difficulty in performing 1 of five basic ADLs. Results: An age adjusted prevalence of 4.6% was found for reported ADL difficulty. Age 85 years (odds ratio [OR] 5.9; 95% confidence interval [CI] 1.1-30.2), history of stroke (OR 9.8; 95% CI 4.1-23.3), history of 1 fall in the past year (OR 3.4; 95% CI 1.6-7.4), low body mass index (OR 2.8; 95% CI 1.2-6.4), and low grip strength (OR 2.6; 95% CI 1.2-5.5) were significantly and independently associated with ADL difficulty. Among women with ADL difficulty, the prevalence of adaptive equipment use was high (>90%). Conclusions: Several characteristics, medical conditions, and behaviours, some of which may be preventable, are associated with physical disability in older New Zealand women. Studies like this are an important step toward the development of interventions to reduce or delay disability and improve health and quality of life.

軟骨異栄養症患者に対する下肢延長術前後のＡＤＬ障害の変化に関する検討

We investigated the change in the difficulties in carrying out activities of daily living (ADL) before and after lengthening of the lower limbs in four patients with achondroplasia and hypochondroplasia. We examined these patients using our ADL evaluation form referred to that of the New York University Medical Center and the Japanese Association of Rehabilitation Medicine. And we also evaluated the degree of satisfaction for the operation using a visual analoge scale. Their preoperative heights were all less than 130cm. After operation, the increases in height were from 6.8cm to 15.5cm. These patients had a significant improvement of their difficulties existing preoperatively due to the shortening of the lower limbs and short stature. And all four patients were satisfied with the conditions after surgery. On the other hand, there were three cases who experienced new subtle difficulties in putting on their socks, tying the shoelaces, manicuring their nails, and one of the three had a shight difficulty in getting on all fours. The results of this study suggested that lengthening of the lower limbs may be an effective strategy for patients with achondroplasia and hypochondroplasia less than 130cm height in order to improve their various ADL difficulties.

Predictors of mobility and basic ADL difficulty among adults aged 70 years and older.

We use data from the 1993-1995 Assets and Health Dynamics of the Oldest-Old survey to estimate predictors of onset of mobility difficulty, onset of basic activity of daily living (ADL) difficulty, and improvement to no mobility difficulty. Onset of mobility difficulty occurred among 20% of those with no difficulty at baseline (n = 2,857) and was most likely among those 85 years of age or over, women, those with a body-mass index of 30 or over, and those who reported lung disease, arthritis, frequent pain, and poor memory. For those with mobility difficulty at baseline (n = 1,871), improvement occurred among 24% and onset of basic ADL difficulty occurred among 25%. Improvement was more likely among those with difficulty in just one mobility item at baseline, and onset of ADL difficulty was most common among those with difficulty in three or more mobility items at baseline.

Functional abilities of elderly coronary heart disease patients.

The impact of coronary heart disease (CHD) on elderly patients' functional abilities is of growing interest because of the increasing number of people that survive the disease. The aim of our study was, firstly, to describe functional abilities among elderly CHD patients and, secondly, to analyze the relationships between physical disability and the severity of chest pain or dyspnea. The third aim was to assess whether there is an independent association between physical disability and CHD. The study was carried out at the health center of the municipality of Lieto, southwestern Finland. From a population of 1196 community-dwelling persons aged > or = 64 years, 89 men and 73 women with CHD (angina pectoris and/or a past myocardial infarction) were selected along with 178 male and 146 female sex- and age-matched controls without CHD. Physical functioning was assessed by means of interviewer-based questionnaires, compared between patients and controls and described in relation to the severity of chest pain and dyspnea among patients. The associations between dependence or difficulties in mobility, ADL (activities of daily living) and IADL (instrumental activities of daily living) and CHD, age, smoking, comorbidities, drug therapy and clinical characteristics were assessed by logistic regression analyses. On items representing mobility and managing in IADL, patients reported more difficulties or dependence than controls. Among female patients, more severe chest pain was associated with poor managing in IADL and tended to be associated with poor mobility. More severe dyspnea was associated with poor mobility among both male and female patients, and with poor managing in IADL among male patients. Logistic regression analyses failed to show that CHD was associated independently with physical disability among the elderly. However, physical disability was associated with the use of cardiovascular drugs in the models among both genders, which probably indirectly indicated an association between physical disability and CHD. Several confounding factors, such as higher age, depression, cancer and the use of psychotropic drugs, contributed to the decline in functional abilities even among persons with CHD. In conclusion, elderly CHD patients have greater limitations in their functional ability than matched controls, which may depend on the severity of the disease. Especially male patients' limitations in physical abilities may be influenced by the fact that men with CHD are more likely to be depressed. Although an independent association between physical disability and CHD was not found, the associations found between physical disability and the use of cardiovascular drugs probably indicate a causal relationship between CHD and physical disability.

Formal education and five‐year mortality in rheumatoid arthritis: Mediation by helplessness scale scores

To analyze scores on a scale designed to measure helplessness, a cognitive variable, as a possible mediator of the association between formal education level and mortality over 5 years in patients with rheumatoid arthritis (RA). A cohort of 1,416 patients with RA from 15 private practices in 6 states and Washington, DC was monitored for over 5 years. Demographic, socioeconomic, therapy, functional status, and psychological variables were analyzed as possible predictors of mortality in invariable and multivariable Cox Proportional Hazards models. In a 5-year followup, 1,384 patients were accounted for (97.3%), including 174 who died versus 111 expected (standardized mortality ratio = 1.54). Higher mortality was associated significantly with low formal education, high age, poor scores for activities of daily living (ADL) on a modified health assessment questionnaire (MHAQ), and poor scores on a helplessness scale (all P < 0.01) in univariable analyses. High age, few years of formal education, and poor MHAQ ADL scores were all significant independent predictors of mortality when analyzed simultaneously in a Cox Proportional Hazards model. When helplessness scale scores were included in a model, scores greater than 2.4 (on a scale of 1 to 4), higher age, male gender, and increased MHAQ ADL difficulty scores were all independently significantly predictive of 5-year mortality (P < 0.05), while years of education was no longer a significant predictor. Scores on a helplessness scale appear to mediate a component of the association between formal education level and 5-year mortality in these patients with RA. Health professionals and policy makers might consider interventions directed at modification of helplessness as adjunctive to standard interventions to improve outcomes in RA.

Comparison and sensitivity to change of self-report scales to assess difficulty, dissatisfaction, and pain in performing activities of daily living over one and five years in rheumatoid arthritis.

We analyzed the longitudinal sensitivity to change of three self-report activities of daily living (ADL) scales over 1 and 5 years in 982 patients with rheumatoid arthritis (RA) from 15 private practices. Over 1 year, the ADL difficulty status worsened in 28.3% of the patients, remained the same in 50.2%, and improved in 21.5%. Over 5 years, 41.3% worsened, 38.8% stayed the same, and 19.9% were improved. Similar percentages for 1- and 5-year changes were found for the ADL dissatisfaction and pain scales. The effect sizes for change over 1 and 5 years for the ADL difficulty, dissatisfaction, and pain scales were--(-)0.05, 0.01, and -0.02, and -0.28, -0.20, and -0.14, respectively, indicating small to moderate declines. These data indicate that the three ADL scales are sensitive to change in status, and ADL change status scores after 1 and 5 years were significantly correlated with each other (r = 0.49-0.68, all p < 0.001). Monitoring of these three constructs may be helpful in the longitudinal evaluation of some patients with RA.

A clue from a self‐report questionnaire to distinguish rheumatoid arthritis from noninflammatory diffuse musculoskeletal pain

A clue to distinguishing rheumatoid arthritis (RA) from noninflammatory diffuse musculoskeletal pain is described on the basis of 2 self-report questionnaire scales, one to assess difficulty in activities of daily living (D-ADL) and a pain visual analog scale (P-VAS). Patients with RA have significantly higher scores on the D-ADL scale compared with the P-VAS scale, while patients with noninflammatory diffuse musculoskeletal pain show the reciprocal pattern. Therefore, the ratio of the P-VAS:D-ADL scores differed significantly in the 2 groups. Ratios of less than 3 were seen in 67% of RA patients versus 28% of patients with noninflammatory diffuse musculoskeletal pain, while ratios greater than 5 were seen in 27% of patients with noninflammatory diffuse musculoskeletal pain, but not in any patients with RA. This simple ratio is clearly not a diagnostic test, but provides an initial approach to diagnosis in rheumatic diseases using a self-report questionnaire.

Learned helplessness in systemic lupus erythematosus: analysis using the rheumatology attitudes index

The Rheumatology Attitudes Index (RAI) was administered to 138 patients with systemic lupus erythematosus (SLE) to determine its reliability and to examine the construct of learned helplessness in patients with this disease. The internal consistency of the RAI was indicated by Cronbach's standardized alpha value (alpha = 0.70). Significant correlations were observed between RAI scores and the Modified Health Assessment Questionnaire Activities of Daily Living difficulty (r = 0.34, P less than or equal to 0.001) and dissatisfaction (r = 0.32, P less than or equal to 0.001) scores, the 10-cm visual analog pain scale (r = 0.42, P less than or equal to 0.001), and the Psychosocial Adjustment to Illness Scale raw total (r = 0.63, P less than or equal to 0.01). These findings support the external validity of the RAI in SLE. In addition, these data suggest that the learned helplessness construct might be relevant to the outcomes of morbidity and mortality in patients with SLE.