Preclinical Disability Research Articles

Exercise for People with Parkinson's Disease: Updates and Future Considerations.

Parkinson's disease (PD) is now the world's fastest-growing neurological disorder with rapidly rising prevalence and increasing demand for effective health services. Recent research has focused on the importance of early diagnosis and proactive management of physical function. Accumulating evidence indicates that reduced physical activity levels and mild pre-clinical disability are present in many people prior to a clinical diagnosis, perhaps developing over years. Early referral to a physiotherapist at the time of diagnosis is now recommended in global guidelines. Multiple forms of exercise have been found to have benefits in early and mid-stage disease across a range of motor and non-motor symptoms. Evidence from longitudinal studies confirms that disability is delayed when regular exercise is sustained over long periods. Exercise is now recognized as an essential component of treatment, in combination with medical therapies. Contemporary physiotherapy interventions now combine health behavior change techniques with physical exercise to promote the development of long-term exercise adherence. Advances in technology and digital health have progressed quickly and now offer opportunities for remote assessment and monitoring, remote exercise supervision, and support adherence through feedback and motivational strategies. Recent biomedical discoveries forecast improved earlier and more accurate diagnosis of PD, allowing opportunities for earlier interventions. Current research in progress will provide important insights into the dose and intensity of aerobic exercise in PD. Physiotherapists have important roles in advocacy and education in conjunction with care delivery to support access to evidence-based care for all people with PD.

Can community‐based cognitive screening identify individuals with MCI associated changes in complex instrumental activities of daily living?

AbstractBackgroundUnrecognized deficits in complex instrumental activities of daily living, termed “preclinical disability”, have been identified in individuals experiencing mild cognitive impairment (MCI: Fieo & Stern, 2018; Peterson et al., 2017). Screening for difficulties in the performance of cognitively demanding complex IADLs may facilitate earlier identification of people on the threshold of MCI and can facilitate earlier intervention (Rodakowski et al., 2014). We examined the ability of three cognitive screening tests to identify individuals reporting IADL problems on the ADCS‐ADL‐MCI scale.MethodsA sample of 87 adults living independently in the community were assessed with the Menu Task, Mini‐Cog, Montreal Cognitive Assessment (MoCA), the ADCS‐ADL, and the 18 and 24 item versions of the ADCS‐MCI‐ADL scale. Established cut‐off scores for each cognitive screen identified impaired and unimpaired groups. Mann‐Whitney U tests compared differences between unimpaired and impaired groups for each cognitive screen on the 18 and 24 item ADCS‐MCI‐ADL composite scores. Between group differences were also examined for each of the ADCS‐MCI‐ADL‐24 individual items.ResultsSample demographics are presented in Table 1. Individuals impaired on the Menu Task had significantly lower composite scores on both the ADCS‐MCI‐ADL‐18 and the ADCS‐MCI‐ADL‐24 (p < .01), although no significant composite score differences were found for the Mini‐Cog (p = .061, p = .155) or the MoCA (p = .053, p = .099). Individual ADCS MCI items were also analyzed to explore the types of IADL impairments identified by each of the three cognitive screens scales. Different patterns of IADL impairment emerged for each of the cognitive screening measures. Individuals impaired on the Mini‐Cog had significantly lower ADCS‐ADL composite scores (p < .05).ConclusionIndividuals living in the community who score as impaired on the Menu Task demonstrated significantly lower ADCS‐MCI‐ADL‐18 and ADCS‐MCI‐ADL‐24 composite scores, but no significant difference on ADCS‐ADL. Impairment on each of the cognitive screening measures was associated with lower scores on individual ADCS‐ADL‐MCI complex IADL items. Cognitive screening measures that detect early and subtle changes in function may lead to earlier diagnosis and interventions for cognitively complex IADL deficits.

Comparison of Mini-Mental State Examination and Montreal Cognitive Assessment Ratings Across Levels of Parkinson's Disease Severity.

Cognitive impairment (CI) is common in Parkinson's disease (PD) and an important cause of disability. Screening facilitates early detection of CI and has implications for management. Preclinical disability is when patients have functional limitations but maintain independence through compensatory measures. The objective of this study was to investigate the relationship between scores on the Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) with levels of PD severity and disability. PD patients (n = 2,234) in a large observational study were stratified by disease severity, based on Total Unified Parkinson's Disease Rating Scale (Total UPDRS) and Hoehn and Yahr (HY) stage. Using MMSE (n = 1,184) or MoCA (n = 1,050) and basic (ADL) and instrumental activities of daily living (IADL) scales for disability, linear regression analysis examined associations between cognitive status and disability. Cognition and disability were highly correlated, with the strongest correlation between IADL and MoCA. Only 16.0% of mean MMSE scores were below threshold for CI (28) and only in advanced PD (Total UPDRS 60+, HY≥3). MoCA scores fell below CI threshold (26) in 66.2% of the sample and earlier in disease (Total UPDRS 30+, HY≥2), corresponding with impairments in ADLs. In a large clinical dataset, a small fraction of MMSE scores fell below cutoff for CI, reinforcing that MMSE is an insensitive screening tool in PD. MoCA scores indicated CI earlier in disease and coincided with disability. This study shows that MoCA, but not MMSE is sensitive to the emergence of early cognitive impairment in PD and correlates with the concomitant onset of disability.

Preventing disability in older adults with mild cognitive impairment: A Strategy Training intervention study.

Non-pharmacological interventions designed to change cognitive function in older adults with Mild Cognitive Impairment have shown mixed results. Few studied interventions directly address preclinical disability. Slowing changes in disability are critical preserve independence and health related quality of life in older adults with Mild Cognitive Impairment. In this study, we discuss the design of the trial, challenges encountered, and solutions generated to guide future trials designed to prevent the onset of disability among at-risk older adults. We compared Strategy Training to enhanced-usual care in 30 older adults with Mild Cognitive Impairment. We recruited 79.7% (n = 188) of the potential participants through direct-to-consumer recruitment. We refined a three-step screening process, including a phone screen, initial in-person screening, and full in-person screening. This screening processes resulted in a high percentage of older adults completing the neuropsychological battery and adjudication of Mild Cognitive Impairment. Conducting a disability prevention among individuals without overt disability is a novel approach. Nevertheless, one of the greatest limitations to our project is the fact that follow-up is restricted to 1 year. Findings from this study can inform the design and conduct of future clinical trials that seek to slow progression of disability in older adults with Mild Cognitive Impairment.

The Predictive Validity of Physical Performance Measures in Determining Markers of Preclinical Disability in Community-Dwelling Middle-Aged and Older Adults: A Systematic Review.

Identification of preclinical disability in middle-aged and older adults might allow early identification of and treatment for functional mobility deficits. This study aimed to determine which physical performance measures (PPMs) were effective in identifying preclinical disability in individuals at risk for future disability. CINHAL, PubMed, Scopus, and Web of Science databases were searched until September 2017 using key words. Two individuals screened peer-reviewed prospective longitudinal studies that assessed healthy individuals>45 years old using PPMs at baseline. Eight studies met inclusion criteria. Two individuals extracted data on participant demographics, PPMs, predictive validity effect size, and disability outcomes. Risk of bias was assessed using the Quality Assessment Tool for Cohort Studies II (Q-Coh II). Four constructs were used to guide data synthesis: functional mobility, activities of daily living disability, fall(s), and hospitalization. Multiple sit-to-stands from a chair, standing balance, and gait speed were found to have some merit in identifying preclinical disability across all 4 disability constructs. All studies were scored as good-quality studies using the Q-Coh II. The heterogeneity in follow-up times and reporting of risk prediction statistics made it difficult to compare results across studies, PPMs, and constructs. The 4 constructs used as markers of preclinical disability potentially do not fully capture the progression of disability. Physical therapists should consider using PPMs on healthy adult populations to gather baseline data during annual health screens for use in identifying preclinical disability.

Could Activity Modifications Indicate Physical Decline Among Adults With Symptomatic Knee Osteoarthritis?

Mobility activity modifications indicate early functional losses that act as precursors to future declines among community-dwelling older adults. However, there is scarce evidence on whether activity modifications indicate poorer physical health among adults with symptomatic osteoarthritis, a major cause of disability. Our purpose was to investigate whether patient-reported mobility activity modifications indicated poorer physical health among adults with symptomatic knee osteoarthritis. Secondary cross-sectional analysis of randomized trial data was performed. Preclinical Disability Questionnaire was used to group participants into the following three categories: difficulty, modified, and no difficulty walking/stair climbing. Kruskal Wallis and χ tests were used to compare clinical factors across groups. Among 121 participants (median age = 60 yrs; 73% female; 60% white), less than 10% had modified walking/stair climbing. Compared with those with no walking difficulty, participants with modified walking had significantly less balance (P = 0.01) and global health (P = 0.01) as well as greater knee pain (P = 0.05) and physical disability (P = 0.04). Those with modified stair climbing had significantly smaller walking distances (P = 0.03) compared with those with no difficulty stair climbing. Activity modifications may signal early impairments in physical health among people with symptomatic knee osteoarthritis. If confirmed, patient-reported activity modifications may enhance symptom evaluation in osteoarthritis and enable a better understanding of the disablement process.

From the May Issue of JAMDA

From the May Issue of JAMDA

The relationship between sleep and physical function in community-dwelling adults: a pilot study.

More than 50% of community-dwelling adults have sleep complaints. Because aging is associated with decline in physical function, coexistent sleep difficulties may exacerbate functional decline. This pilot study explored the relationships between sleep, age, chronic disease burden, and physical function among 50 community-dwelling older adults. Findings revealed significant relationships between total sleep time and preclinical disability (r = -0.33, P ≤ .05) and mobility difficulty (r = -0.36, P ≤ .05). A regression analysis showed that total sleep time was significantly associated with mobility difficulty and preclinical disability, even after controlling for chronic disease burden. These findings suggest that total sleep time may be a catalyst for functional decline.

Can performance on daily activities discriminate between older adults with normal cognitive function and those with mild cognitive impairment?

To examine whether preclinical disability in performance of cognitively focused instrumental activity of daily living (C-IADL) tasks can discriminate between older adults with normal cognitive function and those with mild cognitive impairment (MCI) and, secondarily, to determine the two tasks with the strongest psychometric properties and assess their discriminative ability so as to generate diagnosis-relevant information about cognitive changes associated with MCI and mild neurocognitive disorder according to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, criteria. Secondary analyses of cross-sectional data from a cohort of individuals diagnosed with normal cognitive function or MCI. Pittsburgh, Pennsylvania. Older adults with remitted major depression (N = 157). Diagnosis of cognitive status was made at the Alzheimer's Disease Research Center, University of Pittsburgh. Performance on eight C-IADLs was measured using the criterion-referenced, observation-based Performance Assessment of Self-Care Skills (PASS). Ninety-six older adults with normal cognitive function (mean age 72.5 ± 5.9) and 61 with MCI (mean age 75.5 ± 6.3) participated. The eight C-IADLs demonstrated 81% accuracy in discriminating cognitive status (area under the receiver operating characteristic curve (AUC) = 0.81, P < .001). Two tasks (shopping and checkbook balancing) were the most discriminating (AUC = 0.80, P < .001); they demonstrated similar ability as all eight C-IADLs in determining cognitive status. Assessing performance on these two C-IADLs takes 10 to 15 minutes. This is the first demonstration of the discriminative ability of preclinical disability to distinguish older adults with MCI from cognitively normal older adults. These findings highlight potential tasks that, when measured using the observation-based PASS, demonstrate greater effort for individuals with MCI. These tasks may be considered when attempting to diagnose MCI or mild neurocognitive disorder in clinical practice and research.

Lower extremity mobility limitation and impaired muscle function in women with ulcerative colitis

Background and aimFatigue, weakness and musculoskeletal manifestations are associated with IBD. An impaired nutritional status and a reduced physical activity can contribute to these clinical outcomes, impacting quality of life and increasing disability. This study aims to assess muscle strength and lower limb physical performance in female UC patients, taking into consideration disease activity, body composition and habitual physical activity. MethodsA case-control study was performed including 23 UC female outpatients and 23 age- and BMI-matched healthy women as controls. Quadriceps strength (QS), handgrip strength (HGS), physical performance based measures (five repetitions sit-up test and 4meter gait speed test), body composition (bioelectrical impedance analysis, anthropometry), and habitual physical activity (HPA) levels were assessed. ResultsUC group had decreased QS (−6%; P=0.012), slower sit-up test (−32%; P=0.000), slower gait speed (−17% P=0.002) and decreased HPA level (−30%, P=0.001) compared with controls. No difference in HGS was observed between groups. Logistic regression showed that UC was an independent factor for decreased QS and slower sit-up test, while HPA was a protective factor for impaired gait speed. Multivariate linear regression showed that BMI was independently associated with an improved QS and slower sit-up test in the UC group. ConclusionWomen with UC had decreased lower limb strength and mobility limitations, which were associated with BMI and the level of physical activity. Early evaluation of nutritional status and performance of the lower limbs could identify UC patients with pre-clinical disability who may benefit from earlier health lifestyle modifications.

The Boston Rehabilitative Impairment Study of the Elderly: A Description of Methods

ObjectivesTo describe the methods of a longitudinal cohort study among older adults with preclinical disability. The study aims to address the lack of evidence guiding mobility rehabilitation for older adults by identifying those impairments and impairment combinations that are most responsible for mobility decline and disability progression over 2 years of follow-up. DesignLongitudinal cohort study. SettingMetropolitan-based health care system. ParticipantsCommunity-dwelling primary care patients aged ≥65 years (N=430), with self-reported modification of mobility tasks because of underlying health conditions. InterventionsNot applicable. Main Outcome MeasuresLate Life Function and Disability Instrument (LLFDI) (primary outcome); Short Physical Performance Battery and 400-m walk test (secondary outcomes). ResultsAmong 7403 primary care patients identified as being potentially eligible for participation, 430 were enrolled. Participants have a mean age of 76.5 years, are 68% women, and have on average 4.2 chronic conditions. Mean LLFDI scores are 55.5 for Function and 68.9 and 52.3 for the Disability Limitation and Frequency domains, respectively. ConclusionsCompletion of our study aims will inform development of primary care–based rehabilitative strategies to prevent disability. Additionally, data generated in this investigation can also serve as a vital resource for ancillary studies addressing important questions in rehabilitative science relevant to geriatric care.

Role of self-efficacy (SE) and anxiety among pre-clinically disabled older adults when using compensatory strategies to complete daily tasks

Classic developmental theory suggests that aging is associated with using compensatory strategies to prolong independence. While compensatory strategies are typically considered positive adaptations, they also signify an early phase in the disablement process — commonly known as pre-clinical disability. To build a better understanding of psychological constructs related to these early signs of disability, we examined the contribution of SE and state anxiety on using compensatory strategies among pre-clinically disabled older adults. Compensatory strategies were observed during performance of daily activities in 257 pre-clinically disabled older adults (67.6±7.04), and SE and state anxiety were evaluated prior to performing each task. In univariate models, lower SE and higher anxiety were associated with more compensation (Spearman correlations: 0.15–0.48, p<0.05). Multivariate logistic regression indicated that low SE [Odds Ratio (OR): 1.70; 95% Confidence Interval (CI): 1.40–2.08) and high anxiety (OR: 1.34; 95% CI: 1.10–1.63) were positively associated with using ≥6 compensatory strategies – a level signifying substantial compensation. When considered jointly with SE, the association with anxiety was reversed — higher anxiety demonstrated a lower likelihood of using compensation (OR: 0.70–0.73; 95% CI: 0.50–0.99). The addition of SE might remove the self-defeating cognitions characterizing anxiety allowing the remaining arousal component to appear beneficial. In conclusion, lower SE and higher anxiety are associated with using compensation to complete daily tasks among pre-clinically disabled older adults. Such psychological constructs may contribute to the use of compensatory strategies and represent future intervention targets to help reduce early signs of disability.

Impact of Tai Chi on Impairment, Functional Limitation, and Disability Among Preclinically Disabled Older People: A Randomized Controlled Trial

Day L, Hill KD, Jolley D, Cicuttini F, Flicker L, Segal L. Impact of tai chi on impairment, functional limitation, and disability among preclinically disabled older people: a randomized controlled trial. ObjectivesTo test the effect of tai chi on the progression of preclinical disability to manifest disability compared with seated flexibility exercise, and to examine whether tai chi mediates delayed disability by reducing impairments in musculoskeletal, cardiovascular, and neurologic systems, and related functional limitations. DesignMultisite parallel group individually randomized controlled trial. SettingGeneral community. ParticipantsPreclinically disabled community-dwelling people older than 70 years (n=503), without major medical conditions or moderate to severe cognitive impairment. InterventionModified Sun style tai chi exercise compared with seated flexibility exercise, both programs delivered in groups for 60 minutes twice weekly for 24 weeks. Main Outcome MeasuresDisability measured with the Late-Life Function and Disability Instrument. Secondary outcomes were impairments and functional limitations of the musculoskeletal, neurologic, and cardiovascular systems. ResultsThere was little change within or between the 2 groups. The mean change in the Disability Frequency Score was 0.3 and 0.1 points (100-point scale) for the intervention and control groups, respectively (adjusted difference −.21; 95% confidence interval [CI] −.99 to .56). The mean change in the Disability Limitation Score was −0.1 and −.04 points for the intervention and control groups, respectively (adjusted difference −0.6; 95% CI −2.31 to 1.11). There was little effect on impairments or functional limitations. A higher proportion of intervention participants ceased attending the exercise program (difference=17.9%, 95% CI 9.6–25.8). Multiple imputation of missing data did not change the results. ConclusionsModified Sun style tai chi did not have an impact on impairment, functional limitations, or disability in preclinically disabled older people when delivered for 24 weeks. Withdrawal from the exercise classes was high but did not explain the null result. Improved compliance, or a longer or more intensive program, may be required.

Obesity and use of compensatory strategies to perform common daily activities in pre-clinically disabled older adults

ObjectivesTo examine the association between the use of compensatory strategies to successfully complete common daily activities—an indicator of pre-clinical disability—and body mass in pre-clinically disabled older adults. DesignCross-sectional observational study. ParticipantsTwo hundred and fifty-nine pre-clinically disabled older adults defined as having changed the frequency or manner of performing daily tasks without reporting any difficulty. MeasurementsThe use of compensatory strategies were objectively evaluated using the Modification (MOD) scale—a reliable and valid scale for assessing the manner in which common daily activities were completed. Height and weight were measured to classify participants into the following body mass index (BMI) categories: (1) normal: 18.5–24.9kg/m2, (2) overweight: 25.0–29.9kg/m2, (3) obese class I: 30.0–34.9kg/m2, and (4) obese class II: 35.0–39.9kg/m2. ResultsCompared to other BMI categories, individuals with class II obesity demonstrated a significantly higher probability of using ≥1 compensatory strategies when rising from a chair (30cm height), kneel to stand, stair ascent, stair descent, and supine to stand tasks. When summarized over all tasks, individuals with class II obesity were 18 times more likely to use extensive compensatory strategies (≥6 on MOD scale) compared to normal weight older adults. Similar trends at a lesser magnitude were found in obese and overweight compared to normal weight older adults. ConclusionObesity is associated with extensive use of compensatory strategies when performing common daily tasks prior to the onset of perceived difficulty, thus placing them at higher risk of disability compared to their peers with lower body mass.

Coping with preclinical disability: older women's experiences of everyday activities.

The purpose of this paper is to describe coping practices used by older women during preclinical disability. This paper was derived from qualitative data gathered during a larger multimethod longitudinal study. Twelve women (60 to 80 years of age) participated in baseline functional performance measures and then repeated in-depth interviews and participant observations over 18 months. A hermeneutic approach was used to interpret the in-depth interviews, participant observations, and field notes using three interrelated processes of thematic, exemplar, and identification of paradigm cases to identify coping practices. Women coped with functional decline, such as difficulty getting up from the floor, in many different ways. Coping practices were grouped into five themes: resist, adapt, substitute, endure, and eliminate. These findings suggest that nurses need to realize outward appearances may mask the level of effort required for older women to complete daily activities.

Screening for pre-clinical disability in different residential settings

BackgroundPreventing disability and offering effective interventions to older people during early decline in function is most likely to be effective if those most at risk of progressive disablement are able to be identified. Similarly the ability to easily identify a group with similar functional profile from disparate sectors of the community is of significant benefit to researchers. This study aimed to (1) describe the use of a pre-clinical disability screening tool to select a functionally comparable group of older men and women with early functional limitation from different settings, and (2) explore factors associated with function and disability.MethodsSelf-reported function and disability measured with the Late-Life Function and Disability Instrument along with a range of physical performance measurements were compared across residential settings and gender in a sample of 471 trial participants identified as pre-clinically disabled after being screened with the Fried pre-clinical disability tool. Factors that might lie on the pathway to progressive disablement were identified using multiple linear regression analysis.ResultsWe found that a sample population, screened for pre-clinical disability, had a functional status and disability profile reflecting early functional limitation, regardless of residential setting or gender. Statistical models identified a range of factors associated with function and disability which explained a greater degree of the variation in function, than disability.ConclusionsWe selected a group of people with a comparable function and disability profile, consistent with the pre-clinical stage of disability, from a sample of older Australian men and women from different residential settings using the Fried pre-clinical disability screening tool. The results suggest that the screening tool can be used with greater confidence for research, clinical and population health purposes. Further research is required to examine the validity of the tool. These findings offer insight into the type of impairment factors characterising early functional loss that could be addressed through disability prevention initiatives.Trial RegistrationACTRN01206000431527

Factors Associated with Preclinical Disability and Frailty among HIV-Infected and HIV-Uninfected Women in the Era of cART

HIV-associated immune injury is hypothesized to increase the risk of preclinical disability and frailty via inflammatory pathways. We investigated the role of CD4+ T cell depletion and clinical AIDS on preclinical disability and frailty in HIV-positive women with a history of combination antiretroviral therapy (cART) and HIV-negative women. This was a cross-sectional study nested within the Women's Interagency HIV Study (WIHS), a prospective cohort study initiated in 1994 across five U.S. cities. Questionnaires and tests were performed by 573 HIV-negative and 1206 HIV-positive women. Prevalence ratios were computed using regression models. Severe CD4+ cell depletion was an independent predictor of slowness, weakness, and frailty in HIV-positive women compared with HIV-negative women. Women with CD4+ counts<100 cells/mm3 were 0.13 seconds slower to complete 4 meters (95% CI 0.06-0.21), 1.25 kg weaker (95% CI -2.31--0.19), and had 2.7 times higher prevalence of frailty (95% CI 1.46-5.01). This study is one of the largest studies to administer performance-based tests to investigate disability and frailty in HIV-positive women. HIV-positive women with intact immune systems and without a history of clinical AIDS were no different from HIV-negative women on tests of slowness, weakness, and frailty phenotype.

Indicators of Preclinical Disability: Women's Experiences of an Aging Body

This paper is derived from a larger multimethod longitudinal study of women's bodily experiences and coping practices before the onset of disability. Twelve women participated in repeated performance measures, in-depth interviews of daily life and physically challenging events, and observations of daily activities conducted over 18 months. Interpretive phenomenological analysis of textual data showed that women's bodies provided multiple indicators or symptoms of preclinical disability. These indicators informed the women that their body was out of synch with their environment; conspicuous during social activities; and vulnerable to becoming dependent on others, technology, or assistive devices to accomplish daily activities. Greater attention to bodily indicators or symptoms may offer a practical method for clinicians to identify preclinical disability.

Transitions Among Disability Levels or Death in African American and White Older Women

This study examined the racial differences in probabilities of transitioning across three disability levels of walking (1/2) mile in a community-dwelling population of older women. The sample comprised 436 community-dwelling older women who were among the two-third least disabled women in Baltimore, Maryland. The levels of disability status of walking (1/2) mile included high functioning defined as reporting no difficulty, preclinical disability defined as reports of task modification but no reported difficulty, and disability defined as reported difficulty. First-order Markov transition models were specified to determine whether race influences the types of individual-level transitions between difficulty levels of walking (1/2) mile. Among high-functioning women, African Americans were more likely to be disabled at the next round than their White counterparts. African American women who began with preclinical disability were more likely to die before the next round. After adjusting for age, education, and perceived income inadequacy, African American women tended to have an increased risk of becoming disabled if preclinically disabled than White women. Prevention through identification of individuals at an early phase of decline appears to be key to addressing racial disparities in physical disability even in later life.

Physical Disability and Depressive Symptomatology in an Elderly Population: A Complex Relationship. The Italian Longitudinal Study on Aging (ILSA)

Depressive symptoms (DS) are very frequent in elderly individuals and are associated with negative outcomes. This study was undertaken to evaluate whether DS predict physical disability in this population. A prospective,community-based cohort study, this work included 5,632 individuals aged 65-84 years, who were recruited from the demographic registries of eight Italian municipalities in 1992. The complete data of 3,256 subjects were collected and analyzed. DS were assessed using the Geriatric Depression Scale with a score > or = 10/30 indicating DS. All traditional risk factors for disability established by questionnaires and physical examinations were assessed at baseline. The outcomes were self-reported disability on the activities of daily living (ADL) test and the performance-based physical function assessment (Physical Performance Tests, PPT). The contribution of the predictive variables to the outcomes evaluated after a mean follow-up of 3.5 +/- 0.4 years was assessed using hierarchical logistic nested models. Baseline DS was associated with higher rates of ADL disability (odds ratio [OR] 1.73, 95%confidence interval [CI] 1.12-2.66) and PPT disability (OR 1.83, 95% CI 1.17-2.85)in men and with ADL disability (OR 1.81, 95% CI 1.28 -2.55) in women. The independent predictors of PPT disability in women were arthritis (OR 2.13, 95% CI 1.28 -3.53) and age (OR 1.09; 95% CI 1.03-1.15). This study provides evidence that older persons who report DS are at higher risk of subsequent physical decline. In women, arthritis is a more powerful predictor of preclinical disability, as measured by PPT.