Functional Status Limitations Research Articles

Functional status, life-space mobility, and quality of life: a longitudinal mediation analysis

Using the Wilson-Cleary model of patient outcomes as a conceptual framework, the impact of functional status on health-related quality of life (HRQoL) among older adults was examined, including tests of the mediation provided by life-space mobility. Participants were enrollees in a population-based, longitudinal study of mobility among community-dwelling older adults. Data from four waves of the study equally spaced approximately 18months apart (baseline, 18, 36, and 54months) were used for participants who survived at least 1year beyond the 54-month assessment (n=677). Autoregressive mediation models using longitudinal data and cross-sectional mediation models using baseline data were evaluated and compared using structural equation modeling. The longitudinal autoregressive models supported the mediating role of life-space mobility and suggested that this effect is larger for the mental component summary score than the physical component summary score of the SF-12. Evidence for a reciprocal relationship over time between functional status, measured by ADL difficulty, and life-space mobility was suggested by modification indices; these model elaborations did not alter the substantive meaning of the mediation effects. Mediated effect estimates from longitudinal autoregressive models were generally larger than those from cross-sectional models, suggesting that mediating relationships would have been missed or were potentially underestimated in cross-sectional models. These results support a mediating role for life-space mobility in the relationship between functional status and HRQoL. Functional status limitations might cause diminished HRQoL in part by limiting mobility. Mobility limitations may precede functional status limitations in addition to being a consequence thereof.

The Use of Skype in a Community Hospital Inpatient Palliative Medicine Consultation Service

Skype™, an Internet-based communication tool, has enhanced communication under numerous circumstances. As telemedicine continues to be an increasing part of medical practice, there will be more opportunities to use Skype and similar tools. Numerous scenarios in the lay literature have helped to highlight the potential uses. Although most commonly used to enhance physician-to-patient communication, there has been limited reported use of Skype for patient-to-family communication, especially in end of life and palliative care. Our inpatient Palliative Medicine Consultation Service has offered and used this technology to enhance our patients' quality of life. The objective was to provide another tool for our patients to use to communicate with family and/or friends, especially under circumstances in which clinical symptoms, functional status, financial concerns, or geographic limitations preclude in-person face-to face communication.

Factores pronóstico de mortalidad en los pacientes mayores con fractura de cadera

Background and objectiveThe objective of the study was to describe the population of patients undergoing surgery for hip fracture, to assess the incidence of mortality and identify associated prognostic factors, and to evaluate functionality at one year after surgery. Patients and methodsA retrospective cohort study, with follow-up during the first year after hospital discharge, of patients over 64 years old undergoing surgery for non-traumatic hip fracture during 2008. Variables studied were sociodemographic parameters, clinical complications, functionality and mortality. ResultsA total of 240 patients were included, with a mean age of 83.8 years (SD 7.3), of whom 75.8% were women, 51.7% were ASA III-IV and 28.3% had a Charlson index greater than 2. Surgical delay was greater than 48h in 61.7% of patients, and the mean hospital stay was 19.6 days (SD 15.9). Over three-quarters (76.3%) of the patients had some postoperative complications, the most frequent being cardiovascular and the cognitive disorders. At one year from surgery, 38.4% were able to walk on their own. In hospital mortality was 7.9%, and was 16.7, 20.4 and 24.6% at 3, 6 and 12 months, respectively. Independent prognostic factors of mortality at one year after surgery were: age, ASA score, Charlson index and post-operative cardiovascular and renal complications. ConclusionsHip fracture is associated with a high post-operative morbidity and mortality rate with important limitations in gait and functional status at one year after surgery.

Expectations and outcomes of prolonged mechanical ventilation*

To compare prolonged mechanical ventilation decision-makers' expectations for long-term patient outcomes with prospectively observed outcomes and to characterize important elements of the surrogate-physician interaction surrounding prolonged mechanical ventilation provision. Prolonged mechanical ventilation provision is increasing markedly despite poor patient outcomes. Misunderstanding prognosis in the prolonged mechanical ventilation decision-making process could provide an explanation for this phenomenon. Prospective observational cohort study. Academic medical center. A total of 126 patients receiving prolonged mechanical ventilation. None. Participants were interviewed at the time of tracheostomy placement about their expectations for 1-yr patient survival, functional status, and quality of life. These expectations were then compared with observed 1-yr outcomes measured with validated questionnaires. The 1-yr follow-up was 100%, with the exception of patient death or cognitive inability to complete interviews. At 1 yr, only 11 patients (9%) were alive and independent of major functional status limitations. Most surrogates reported high baseline expectations for 1-yr patient survival (n = 117, 93%), functional status (n = 90, 71%), and quality of life (n = 105, 83%). In contrast, fewer physicians described high expectations for survival (n = 54, 43%), functional status (n = 7, 6%), and quality of life (n = 5, 4%). Surrogate-physician pair concordance in expectations was poor (all kappa = <0.08), as was their accuracy in outcome prediction (range = 23%-44%). Just 33 surrogates (26%) reported that physicians discussed what to expect for patients' likely future survival, general health, and caregiving needs. One-year patient outcomes for prolonged mechanical ventilation patients were significantly worse than expected by patients' surrogates and physicians. Lack of prognostication about outcomes, discordance between surrogates and physicians about potential outcomes, and surrogates' unreasonably optimistic expectations seem to be potentially modifiable deficiencies in surrogate-physician interactions.

Joint functional disability in children of early age with olygoarticular juvenile arthritis

Система комплексной поддержки и сопровождения научного журнала Elpub позволяет запустить двуязычный сайт журнала со встроенной системой электронной редакции в соответствии с лучшими издательскими практиками, а так же предусматривает техническую и методическую поддержку со стороны специалистов НЭИКОН.

Findings of extensive variation in the types of outcome measures used in hip and knee replacement clinical trials: A systematic review

To describe the extent of variation in outcome measure usage in hip and knee replacement randomized trial literature, and to summarize this variation in the context of the International Classification of Functioning, Disability, and Health (ICF) conceptual model created by the World Health Organization (WHO). We used a defined search strategy in Medline and EMBase databases to identify articles published from January 2000 to February 2007. Studies were reviewed if they were randomized trials with a >or=6-week followup and if they used noninvasive outcome measures of impaired joint function or whole-person limitations in daily activities or functional status. The WHO ICF model was used to categorize outcome measures. Of 972 studies, 160 were included for review. Of these, 82 were conducted on patients with hip replacements, 75 on patients with knee replacements, and 3 on patients with both. The most common outcome measure in knee trials was the American Knee Society score (used in 48% of reviewed studies), and in hip trials was the Harris hip score (52.4%). At least 20 different outcome measures were used in the hip trials, and at least 14 different measures were used in knee trials. The primary outcome was identified in only 24% of trials. We found extensive variation in outcome measures across trials and saw inconsistency across the components of the WHO ICF model. To improve interpretability, future work should determine whether consensus can be developed for a standardized set of outcome measures for hip and knee replacement trials.

The Multi-Ethnic Pediatric Eye Disease Study: Design and Methods

Purpose: To summarize the study design of the Multi-Ethnic Pediatric Eye Disease Study (MEPEDS). Methods: The objectives of the MEPEDS are to: (1) estimate age- and ethnicity-specific prevalence of strabismus, amblyopia, and refractive error; (2) evaluate the association of selected risk factors with these ocular disorders; and (3) evaluate the association of ocular conditions on limitations in health-related functional status in a population-based sample of 12,000 children aged 6–72 months from four ethnic groups—African-American, Asian-American, Hispanics/Latinos and non-Hispanic White. Each eligible child undergoes an eye examination, which includes an interview with his/her parent. The interview includes an assessment of demographic, behavioral, biological, and ocular risk factors and health-related functional status. The examination includes fixation preference testing, visual acuity, stereoacuity, axial length measurement, cycloplegic refraction, keratometry, eye alignment, and anterior and posterior segment examination.

Functional status is a confounder of the association of influenza vaccine and risk of all cause mortality in seniors

Functional status limitations may be associated with both an increased risk of death and a decreased likelihood of influenza vaccination, and so may confound the association of influenza vaccination and risk of all cause mortality in seniors. We conducted a nested case-control study of persons >or=65 years of age that included 252 cases who died during an influenza season and 576 age-matched controls. We identified functional limitations by medical record review, and compared the effect of adjustment for those factors with that of adjustment for disease covariates defined by diagnosis codes, using methods reported by previous influenza vaccine effectiveness studies, on the association of influenza vaccination and risk of death. Functional limitations, such as requiring assistance for bathing, were highly prevalent in cases, even in the subgroup defined as free of comorbidity by diagnosis code criteria, and were associated with a decreased likelihood of vaccination among controls. Adjustment for functional limitations resulted in an estimate of the relative risk of death in vaccinated persons compared with unvaccinated persons that was closer to the null [odds ratio (OR), 0.71; 95% confidence interval (95% CI), 0.47-1.06] than the unadjusted estimate (OR, 0.59; 95% CI, 0.41-0.83). In contrast, adjustment for diagnosis code covariates moved the estimate further from the null (OR, 0.45; 95% CI, 0.30-0.68). Functional limitations appear to be important confounders of the association of vaccination and risk of death, while adjustment for diagnosis code covariates did not control for a healthy vaccinee bias. Further research is needed on methods to reduce the influence of bias in observational studies of influenza vaccine effectiveness.

Assessing Improvement in Patients Who Report Small Limitations in Functional Status on Condition-Specific Measures

Purpose: Our purpose was to describe the challenges associated with detecting improvement of patients who present with small but important limitations in functional status. There are three components to this article: (1) introduction of the challenges, (2) presentation of proposed solutions, and (3) case illustrations. Summary of Key Points: Three factors contribute to the identified challenges: (1) little room is available on the scale to detect improvement, (2) regression towards the mean, and (3) the nonlinear properties of most self-report measures. Two strategies were identified to overcome these challenges: (1) to average the results of measurements performed on different occasions and (2) to apply a patient-specific measure. Examples of the successful application of these strategies are presented for two patients with low back pain. Conclusions: Averaging measurements taken on different occasions and applying patient-specific measures represent effective strategies for detecting improvement in patients who present with small limitations in functional status.

Assessing Improvement in Patients Who Report Small Limitations in Functional Status on Condition-Specific Measures

Purpose: Our purpose was to describe the challenges associated with detecting improvement of patients who present with small but important limitations in functional status. There are three components to this article: (1) introduction of the challenges, (2) presentation of proposed solutions, and (3) case illustrations.

Correlates of functional status 3-5 years after traumatic brain injury with CT abnormalities.

The Functional Status Examination (FSE) is a relatively new measure of functional outcome after traumatic brain injury (TBI). This study examines functional status limitations and what contributes to them to further enhance interpretability of the FSE and to continue its development as an outcome measure. The measure was given to 209 adults sustaining TBI with CT abnormalities who were followed prospectively until three to five years after injury. Relationships between functional status change as assessed by the FSE and characteristics of the injury and pre-injury characteristics of the person injured were evaluated as were relationships with concurrent measures of neuropsychological, emotional, and psychosocial functioning, health status, quality of life, and other functional status measures. Groups based on degree of functional status limitations due to the injury differ significantly on injury severity, especially length of impaired consciousness. They do not differ on most pre-injury characteristics of the person injured, although pre-existing conditions, primarily alcohol abuse, are more common in those with more negative functional changes after injury. All concurrent measures examined differ significantly among FSE groups with strongest relationships with measures of quality of life, psychosocial functioning, and other measures of health status and functional status (each p < 0.001). The Functional Status Examination shows promise as a measure reflecting a broad range of functional limitations. The FSE is an excellent tool combining clinical relevance, face validity, strong relationships to other measures of relevant constructs (criterion-related validity), and reasonable sensitivity to TBI severity even long after the injury and in a mostly moderately injured group.

Participation of patients 65 years of age or older in cancer clinical trials.

Although 61% of new cases of cancer occur among the elderly, recent studies indicate that the elderly comprise only 25% of participants in cancer clinical trials. Further investigation into the reasons for low elderly participation is warranted. Our objective was to evaluate the participation of the elderly in clinical trials sponsored by the National Cancer Institute (NCI) and assess the impact of protocol exclusion criteria on elderly participation. We conducted a retrospective analysis using NCI data, analyzing patient and trial characteristics for 59,300 patients enrolled onto 495 NCI-sponsored, cooperative group trials, active from 1997 through 2000. Our main outcome measure was the proportion of elderly patients enrolled onto cancer clinical trials compared with the proportion of incident cancer patients who are elderly. Overall, 32% of participants in phase II and III clinical trials were elderly, compared with 61% of patients with incident cancers in the United States who are elderly. The degree of underrepresentation was more pronounced in trials for early-stage cancers than in trials for late-stage cancers (P <.001). Furthermore, protocol exclusion criteria on the basis of organ-system abnormalities and functional status limitations were associated with lower elderly participation. We estimate that if protocol exclusions were relaxed, elderly participation in cancer trials would be 60%. The elderly are underrepresented in cancer clinical trials relative to their disease burden. Older patients are more likely to have medical histories that make them ineligible for clinical trials because of protocol exclusions. Insurance coverage for clinical trials is one step toward improvement of elderly access to clinical trials. Without a change in study design or requirements, this step may not be sufficient.

Functional Status and Nutrient Intake from the Council on Aging Meal and Total Daily Intake of Congregate, Adult Day Care and Homebound Program Participants

ABSTRACT Functional status and nutrient intake among 52 congregate, 30 day care and 31 homebound Council on Aging (COA) participants were evaluated by data from three 24-hour dietary recalls, ADLs and IADLs along with demographic variables and analyzed by analysis of variance. Congregate subjects had fewer functional status limitations. The COA meals provided one-third of the RDA for most nutrients; however, total daily intake was inadequate in several nutrients. Those living with younger relatives and homebound/day care men had significantly (p < 0.05) highest total daily intake. Positive benefits from the COA meals were supported. Service providers need to monitor both total day's intake and the COA meals.

Functional impairment associated with acute poststroke depression: the Stroke Data Bank Study.

To examine the independent association of depression following acute stroke with impairment in activities of daily living (ADL), the authors conducted a cross-sectional analysis of stroke patients enrolled in the Stroke Data Bank (U.S.A.) who had completed the Center for Epidemiological Studies Depression Scale (CES-D). Scores on the Barthel Index, a measure of ADL, were compared between depressed (CES-D > or = 16) and nondepressed patients (CES-D < or = 15) at 7-10 days after stroke. Of the 626 who completed CES-D, 160 were depressed. Depressed stroke patients evidenced greater impairment in ADL than nondepressed patients, independently of all other factors that influenced poststroke physical disabilities. CES-D scores were negatively correlated with Barthel scores in the entire stroke population. Neurological factors, greater age, poor prestroke physical activity, and prestroke disturbances in sexual functioning were also independently associated with limitations in functional status of stroke patients.

Self-Care and Assistance from others in Coping with Functional Status Limitations among a National Sample of Older Adults

Using data from the first wave of a new longitudinal data set collected in the late fall and winter of 1990-1991, the National Survey of Self-Care and Aging (NSSCA), we examined older adults' self-care practices in coping with functional status limitations based on in-person interviews with a national probability sample of 3,485 noninstitutionalized adults aged 65 or older selected from Medicare beneficiary files. A composite score of functional status was calculated to reflect the presence and severity of disability in three dimensions: basic, mobility, and instrumental activities of daily living. Three types of self-care coping strategies were defined: use of equipment or devices, changes in behavior, and modifications in one's environment. National estimates of self-care practices, assistance from others, and functional status measures were presented. Data revealed that the likelihood of engaging in self-care coping strategies increased as the severity of disability increased, except among the most severely disabled. Generally, those receiving assistance from others were more likely to engage in self-care activities, suggesting that receiving assistance supplements, rather than supplants, self-care coping strategies.