Valued Life Activities Research Articles

Re: What Matters? The Valued Life Activities of Older Adults Undergoing Elective Surgery.

Re: What Matters? The Valued Life Activities of Older Adults Undergoing Elective Surgery.

630 Fear Avoidance Beliefs and Behaviours of Burn Survivors: A Mixed Methods Approach

Abstract Introduction The Fear-Avoidance (FA) Model describes a cascade of events after pain that is perceived as threatening, which may lead to avoidance of valued and meaningful life activities and greater disability. Literature examining burn survivors (BS) suggests they may experience FA, however, the evaluation tool that has been used is four items extracted from the Tampa Scale of Kinesiophobia that were modified for BS, but never formally validated with this population. Therefore, the aim of this study was to explore the lived-experience of BS with respect to FA and determine whether the questionnaire reflects and accurately measures their lived-experience. Methods A mixed methods approach was used with quantitative data collected using the modified questionnaire followed by individual interviews to gather qualitative data about the participants’ opinion and perceived relevance of the questionnaire using cognitive debriefing as well as their lived-experience of FA. Participants were recruited using purposeful sampling so that a range of FA beliefs and behaviors were explored. The inclusion criteria were adults BS who required hospitalization and skin grafting whose burn injury occurred within the past 3 years. Results 17 participants (9 ♂, 8 ♀, mean age = 51, mean TBSA burned = 22%, mean days post-burn = 458). The overall mean score of the questionnaire was 1.63 where >1 is considered FA. Five major themes emerged from the thematic analysis of the interviews: perceived vulnerability to re-injury; others as fear influencers; difficulties & hardships during recovery; engagement in activity, and active thoughts. The questionnaire results identified 12 FA participants vs 9 based on the interviews. Only one of the questions was able to discriminate FA participants from non FA participants and none of the current questions clearly resonated with BS. Conclusions This study demonstrated that the modified questionnaire did not demonstrate the ability to quantify or reflect the BS lived-experience of FA. However, this remains an important issue since more than half of the participants reported avoiding engagement in valued life activities due to fear of pain or injury even months or years after their injury. Further research should focus on protective factors that may aid patients in reducing or preventing FA. Applicability of Research to Practice FA should be evaluated and addressed with BS using an assessment tool that has been specifically validated with this population.

Aging Well in the Digital Age: Technology in Processes of Selective Optimization with Compensation.

Studies show that using information and communication technology (ICT) contributes significantly to elders' subjective well-being (SWB). Drawing on the Selective Optimization with Compensation (SOC) model, this study aims at exploring the mechanism by which ICT use helps older adults remain engaged in valued life activities and maintain their SWB. Involving teams from seven countries (Canada, Colombia, Israel, Italy, Peru, Romania, Spain), 27 focus groups were conducted with a total of 184 grandmothers aged 65 years and older who use ICT. Analysis led to identification of a series of strategies related to ICT use that may be described in SOC terms. "Intentional limited use" and "Selective timing,", for example, are clearly associated with selection. In addition, numerous optimizing strategies were found to be applied in "Instrumental" and "Leisure" activities, whereas some ICT uses offered compensation for "Aging-related" and "General" challenging circumstances. The study suggests that ICT is used in all three SOC processes and that its effective application facilitates adjustment and enhances SWB. It should therefore be regarded as a resource that supports existing personal and social resources and life management strategies, and even as a Quality of Life Technology that maintains or enhances functioning in older adulthood.

What Matters? The Valued Life Activities of Older Adults Undergoing Elective Surgery.

Valued life activities are those activities an individual deems particularly important or meaningful. Surgery in older adults can affect their ability to perform valued activities, but data are lacking. We characterized these activities and assessed performance of them following surgery. Retrospective observational study. Preoperative program for older adults undergoing elective surgery at an academic hospital. Older adults (N = 194) in the program from February 2015 to February 2018. A preoperative written questionnaire asked, "What are the activities that are most important to you to be able to do when you return home from surgery?" Participants could list up to three activities. Content analysis was used to develop domains of valued life activities and categorize responses. Postoperative questionnaires and medical records were used to determine ability to perform activities 6 months after surgery. Of 194 participants (mean age = 74.9 ± 9.1 y), 57.7% were female; 33.5% had more than two comorbid conditions. We elicited 510 valued activities, with a mean of 2.6 (± .7) activities per participant. Content analysis revealed five categories: (1) recreational activities (28.9%); (2) mobility (24.9%); (3) activities of daily living (ADLs; 17.5%); (4) instrumental activities of daily living (IADLs; 16.9%); and (5) social activities (12.0%). Ultimately, 154 participants had surgery, of which 27.3% were unable to perform one of their valued activities at 6 months. Performance varied between activity categories; 91.9% of mobility activities, 90.8% of ADLs, 80.3% of IADLs, 77.3% of social activities, and 65.5% of recreational activities were able to be performed after surgery. Older adults expressed a wide range of valued life activities. More than one-quarter were unable to engage in at least one valued life activity after surgery, with recreation the most commonly affected. Assessment of valued life activities should be incorporated into the perioperative management of older adults. J Am Geriatr Soc 67:2305-2310, 2019.

One-Day Behavioral Intervention for Distressed Veterans with Migraine: Results of a Multimethod Pilot Study.

Migraine, a chronic neurological disorder characterized by episodic severe headache pain and functional impairment, affects approximately 12% of the general US population. Veterans returning from Iraq or Afghanistan have two to four times the incidence of migraine of the general population. Veterans with migraines are more than twice as likely to have comorbid psychiatric conditions as veterans without migraines, with depression and post-traumatic stress disorder being most prevalent. This psychiatric-migraine comorbidity is of major public health significance, as it leads to decreased quality of life, poorer response to migraine and mental health treatment, and overall worse prognosis. Unfortunately, acceptable and effective treatments for these comorbid problems have rarely been investigated. The aims of this study are to examine the acceptability, feasibility, and preliminary efficacy of a 1-d acceptance and commitment therapy (ACT) plus Migraine Education workshop. Twenty-five veterans with migraines and co-occurring depression and/or anxiety completed the 1-d ACT plus Migraine Education workshop. Veterans completed assessments of depressive and anxiety symptoms, general functioning, headache-related disability, and ACT-specific skills at baseline and 3 mo after the workshop. Changes from baseline to 3-mo follow-up on the self-report and clinician-rated measures were assessed using the paired t-test and Wilcoxon signed-rank test. Veterans also completed semistructured qualitative interviews documenting their experiences with the workshop 2 wk and 3 mo following the intervention. Qualitative data were analyzed via directed content analysis. Individual codes were aggregated into larger themes agreed upon by consensus. At 3-mo follow-up, veterans significantly improved in depressive and anxiety symptoms, general functioning, and headache-related disability compared with baseline. Additionally, veterans significantly improved in pain acceptance and engagement in valued life areas. In interviews, veterans indicated that the migraine education helped them feel more knowledgeable about their condition, and this empowered them to better manage their headaches, including talking to their physician about medication adjustments. The ACT component led to greater awareness of the role stress plays in exacerbating pain and ways to manage this stress, including greater acceptance and greater engagement in valued life activities. For some, however, the role of stress in exacerbating migraines needed to be highlighted more. Veterans appreciated being in a group with other veterans with similar health difficulties and wanted this to be incorporated into ongoing care at the Veterans Affairs medical center. The patient education manuals were useful to the veterans, with some referring to them during the months following the workshop. Findings of this small trial have important implications pending replication in a more rigorously designed large-scale study. A 1-d ACT plus Migraine Education workshop is an acceptable and feasible treatment approach for veterans with migraines and significant distress. Significantly reduced distress and disability, as well as improved coping skills, suggest that veterans were activated to engage more fully in their lives and clinical care. The availability of an effective transdiagnostic intervention that can be completed in 1 d is particularly valuable for veterans who have multiple comorbid conditions and who encounter practical barriers to engaging in the usual prescribed weekly therapy treatments.

I132 Managing fatigue in Sjögren’s syndrome

Fatigue is a dominant symptom for approximately 70% of people with primary Sjogren’s syndrome (PSS) and a symptom which patients report as needing improvement. It has a negative impact on quality of life and affects patients’ ability to participate in valued life activities. For many patients, there are assignable causes for their fatigue, including co-morbidities and side effects of medication. We have identified the main predictors of fatigue in the UKPSSR cohort and tested for differences between those with assignable causes of fatigue (co-morbidities and medications associated with drowsiness) and those who have no assignable causes for their fatigue. In light of these findings, appropriate clinical interventions to manage fatigue in PSS patients will be discussed, including the Newcastle multi-disciplinary CRESTA Fatigue clinic model. Data from the first cohort of 50 PSS patients who have accessed the CRESTA fatigue service will also be presented.

Activity limitations and subjective well-being after stroke.

As limitations in activities of daily living are major components of many stroke outcome scales, we examined how well activity limitations predicted subjective well-being among stroke survivors in a nationally representative survey. Individuals with a self-reported history of stroke were identified from the National Health and Aging Trends Study. Subjective well-being (primary outcome) was assessed with a validated 7-item measure (higher = greater well-being) assessing emotions (cheerful, bored, full of life, and upset) and self-realization (purpose in life, self-acceptance, and environmental mastery). Activity limitations were defined by the receipt of help in any of 11 activities of daily living/instrumental activities of daily living. Multivariable linear regression assessed predictors of well-being including medical, physical, cognitive, psychological, and environmental factors. A total of 738 stroke survivors age 65 or older were included (57% female, 9% African American, 6% Hispanic). Activity limitations were modestly associated with well-being after adjusting for demographic characteristics and availability of assistance (estimate -0.49, 95% confidence interval -0.61 to -0.37). However, in the fully adjusted model (R2 = 0.28), neither activity limitations nor physical capacity was associated with subjective well-being. Predictors of lower well-being in the final model included depressive symptoms, chewing/swallowing problems, pain that limited activity, and restricted participation in valued life activities. Income and executive function were modestly associated with improved well-being, while comorbidities and communication technology access were not associated. Activity limitations were not associated with stroke survivors' subjective well-being after adjustment for other factors. While some predictors of well-being after stroke were identified, the determinants of well-being remained largely unexplained.

Assessment of muscle mass relative to fat mass and associations with physical functioning in rheumatoid arthritis.

To determine whether a novel measure of appendicular lean mass relative to fat mass is associated with physical functioning in RA. In a cross-sectional design, three independent RA cohorts were retrospectively analysed. Whole-body DXA measures of appendicular lean mass index (ALMI, kg/m 2 ) and fat mass index (FMI, kg/m 2 ) were converted to age, sex and race-specific Z-scores using published National Health and Nutrition Examination Survey reference ranges. Adiposity-adjusted ALMI Z-scores (ALMI FMI ) were determined using a published method to adjust for normal associations between ALMI and FMI Z-scores. Associations between ALMI Z-scores, ALMI FMI Z-scores and physical functioning were assessed after adjusting for age, sex and study. Functional outcomes assessed included the HAQ, Valued Life Activities assessment and Short Physical Performance Battery. Low lean for age was defined as a Z-score of -1 or less. Our sample consisted of 442 patients with RA. The combined cohort had a mean ALMI Z-score of - 0.51 (1.08) and a mean ALMI FMI Z-score of - 0.58 (1.53), suggesting muscle mass deficits compared with a nationally representative sample. Greater ALMI FMI Z-scores demonstrated stronger associations with better functional outcomes compared with ALMI Z-scores. Associations were not attenuated with adjustment for systemic inflammation or pain. The FMI Z-score was independently associated with physical functioning, with a stronger association seen among patients with greater FMI Z-score. Adiposity-adjusted definitions of low lean mass more clearly identified those with functional impairment. Estimates of appendicular lean mass that are adjusted for adiposity demonstrate stronger positive associations with functional outcomes compared with unadjusted estimates.

Is frailty a relevant concept in SLE?

ObjectiveIn geriatric populations, frailty is associated with poor health outcomes, including mortality. Frailty has not been examined in lupus, although components of the phenotype seem relevant.MethodsWomen with lupus (n=152) participated...

Frailty and reduced physical function go hand in hand in adults with rheumatoid arthritis: a US observational cohort study.

Reduced physical function and health-related quality of life are common in rheumatoid arthritis (RA), and further studies are needed that examine novel determinates of reduced physical function in RA. This study examines whether frailty, a state of increased vulnerability to stressors, is associated with differences in self-reported physical function among adults with RA. Adults from a longitudinal RA cohort (n=124) participated in the study. Using an established definition of frailty, individuals with three or more of the following physical deficits were classified as frail: (1) body mass index ≤18.5, (2) low grip strength (adjusted for sex and body mass index (BMI), measured by handheld dynamometer), (3) severe fatigue (measured by the Multidimensional Assessment of Fatigue), (4) slow 4-m walking speed (adjusted for sex and height), and (5) low physical activity (measured by the International Physical Activity Questionnaire). Individuals with one or two deficits were classified as "pre-frail" and those with no deficits as "robust." Self-reported physical function was assessed by the Health Assessment Questionnaire (HAQ) and the Valued Life Activities Difficulty scale. Regression analyses modeled associations of frailty category with HAQ and Valued Life Activities (VLA) Difficulty scores with and without controlling for age, sex, disease duration, C-reactive protein, use of oral steroids, and pain. Among adults with RA, being frail compared to being robust was associated with a 0.44 worse VLA score (p<0.01) when the effects of covariates are held constant. Being frail, compared to being robust, is associated with clinically meaningful differences in self-reported physical function among adults with RA.

Examining age-related differences in support needs on the Supports Intensity Scale-Children's Version-Spanish translation

Background: Interest in the support needs of people with intellectual disability has directed attention to developing assessments to measure of the pattern and intensity of supports which people need to participate in valued life activities. Assessments of the support needs of children must account for the influence of age. Method: Four hundred fifty (450) Spanish children with intellectual disability (ages 5-16) were assessed with the SIS-C Spanish. To test for measurement invariance and latent differences, the SIS-C Spanish standardization sample was linked to the SIS-C English normative sample. Models developed during the norming process were used to investigate measurement equivalence across age groups, differences in latent means, and differences in latent variances and standard deviations. Results: Findings suggested that all items on the SIS-C Spanish could reliably be used to measure support needs of children ages 5-16. When exploring age-related differences at the latent level, however, data showed latent mean differences in support need domain scores across age cohorts. Conclusions: The same set of items can be used to measure support needs in children ages 5-16, but age-related influences must be considered in developing norms for the SIS-C Spanish as well as in planning supports for children.

Validation and internal consistency of the Swedish version of the Valued Life Activities scale

Objective: The objective was to create a linguistically and culturally validated Swedish version of the Valued Life Activities scale. The aim was also to describe its content and concurrent validity and its internal consistency in persons with rheumatoid arthritis. Methods: The Valued Life Activities scale was translated to Swedish and culturally adapted. In order to describe the content validity, both the Swedish and original Valued Life Activities scale were linked to the International Classification of Functioning, Disability and Health. The concurrent validity and internal consistency were evaluated in 737 patients with rheumatoid arthritis. To establish concurrent validity, the scale was correlated to disease activity, activity limitations, and life satisfaction. Internal consistency was assessed with Cronbach’s alpha. Results: The equivalence of meaning between the Swedish and the original Valued Life Activities scale was ensured by harmonization review. Content validity was high when linked to the International Classification of Functioning, Disability and Health. Concurrent validity showed a strong correlation with the activity limitations (r = 0.87), moderate with life satisfaction (r = –0.61), and weak with disease activity (r = 0.38). Internal consistency was excellent (Cronbach’s alpha = 0.97). Conclusions: The Swedish Valued Life Activities scale has been tested in a large and well-characterized sample and found to be a linguistically valid and culturally adapted self-reported measure of participation. Content validity of the Valued Life Activities scale was excellent, concurrent validity strong, and the internal consistency excellent. Since both individual preferences and International Classification of Functioning, Disability and Health concepts of disability are taken into account, the Swedish Valued Life Activities scale appears to be a promising new scale addressing important aspects of participation.

Self-efficacy and pain acceptance as mediators of the relationship between pain and performance of valued life activities in women and men with rheumatoid arthritis

Objective: To study whether personal factors (self-efficacy and pain acceptance) mediate the relationship between pain and performance of valued life activities in persons with rheumatoid arthritis. Methods: Persons with rheumatoid arthritis for at least four years (n = 737; 73% women) answered a questionnaire measuring self-efficacy, pain acceptance, performance of valued life activities, and self-rated pain. Relationships among these constructs were explored using univariate and multivariate analyses. Structural equation modelling was then used to examine the mediational role of personal factors on the relationship between pain and performance of valued life activities. Results: A direct negative association between pain and performance of valued life activities was identified (Beta = .34, P < .001). This suggests that people with rheumatoid arthritis who had higher levels of pain has increased difficulties in performing valued life activities. Self-efficacy and activity engagement component of pain acceptance mediated the relationship between pain and performance of valued life activities, however the pain willingness component of pain acceptance did not influence participation in valued life activities. Conclusion: These findings highlight the importance of considering personal factors, such as pain acceptance and self-efficacy, in facilitating participation in valued life activities.

Abstract 187: Are Limitations in Activities of Daily Living the Best Predictor of Well-Being After Stroke?

Objective: Limitations in activities of daily living are major components of most stroke outcome scales. We examined whether activity limitations or other factors predicted self-reported well-being among stroke survivors in a large nationally representative survey. Methods: Individuals with a self-reported history of stroke were identified from the National Health and Aging Tends Study (NHATS wave 1, year 2011). Self-reported well-being (primary outcome) was defined based on a previously validated 7-item measure (higher=greater well-being) assessing emotions (feeling cheerful, bored, full of life, or upset) and self-realization (purpose in life, self-acceptance, and environmental mastery). Activity limitations were defined by the need for assistance in any of 11 activities of daily living/instrumental activities of daily living (ADLS/IADLS). Multivariable linear regression was used to identify factors associated with well-being. Results: 738 stroke survivors 65 or older were included (57% female, 9% African American, 6% Hispanic). The final multivariable model (see Table) only modestly explained the total variability in well-being (R-squared=0.28). Number of ADL/IADL limitations was not associated with well being. Notable predictors of lower well being included depressive symptoms, chewing problems, pain that limited activity, and restricted ability to participate in valued life activities. Income was modestly associated with improved well-being, while social network support and access to communication technology were not associated. Conclusions: Limitations in ADLs/IADLs were not predictive of well-being in this population of stroke survivors, which raises the question of whether existing outcome scales adequately measure the most important patient-centered outcomes. Much of what determines well-being among stroke survivors remains unexplained.

Frailty Phenotypes, Disability, and Outcomes in Adult Candidates for Lung Transplantation.

Frailty is associated with morbidity and mortality in abdominal organ transplantation but has not been examined in lung transplantation. To examine the construct and predictive validity of frailty phenotypes in lung transplant candidates. In a multicenter prospective cohort, we measured frailty with the Fried Frailty Phenotype (FFP) and Short Physical Performance Battery (SPPB). We evaluated construct validity through comparisons with conceptually related factors. In a nested case-control study of frail and nonfrail subjects, we measured serum IL-6, tumor necrosis factor receptor 1, insulin-like growth factor I, and leptin. We estimated the association between frailty and disability using the Lung Transplant Valued Life Activities disability scale. We estimated the association between frailty and risk of delisting or death before transplant using multivariate logistic and Cox models, respectively. Of 395 subjects, 354 completed FFP assessments and 262 completed SPPB assessments; 28% were frail by FFP (95% confidence interval [CI], 24-33%) and 10% based on the SPPB (95% CI, 7-14%). By either measure, frailty correlated more strongly with exercise capacity and grip strength than with lung function. Frail subjects tended to have higher plasma IL-6 and tumor necrosis factor receptor 1 and lower insulin-like growth factor I and leptin. Frailty by either measure was associated with greater disability. After adjusting for age, sex, diagnosis, and transplant center, both FFP and SPPB were associated with increased risk of delisting or death before lung transplant. For every 1-point worsening in score, hazard ratios were 1.30 (95% CI, 1.01-1.67) for FFP and 1.53 (95% CI, 1.19-1.59) for SPPB. Frailty is prevalent among lung transplant candidates and is independently associated with greater disability and an increased risk of delisting or death.

Clarity of Personal Values and Committed Action: Development of a Shorter Engaged Living Scale

The Engaged Living Scale (ELS) is a measure of the process of engaged living, defined by Acceptance and Commitment Therapy as the evaluation and performance of valued life activities. This 16-item measure was recently created and has been validated in middle-aged and chronic pain samples. The aim of the present study was to validate the ELS-16 in a young-adult sample and additionally to develop a shorter ELS. This study was conducted using different samples of Portuguese young-adult college students. The dimensionality of the ELS-16 (which was translated to Portuguese from the original Dutch) was tested through a CFA. The adequacy of the shorter ELS (ELS-9) was also tested through a CFA. The scales’ internal reliability and other psychometric qualities were additionally analysed. Results from the CFA suggested that the model benefits from the establishment of correlations between pairs of error terms of items with similar contents. These results led to the decision to shorten the measure by excluding the item of each pair with the lowest communalities. The ELS-9 was then created and its CFA results revealed good to excellent adjustment values and goodness-of-fit indices. Results also showed that the ELS-16 and the ELS-9 present adequate to good psychometric properties. The present study thus shows that these instruments seem to be reliable measures of engaged living and to perform adequately in young-adult college students, with the ELS-9 being a new contribution to health research and allowing faster administrations.

Difficulty and Importance of Valued Occupations for People With Scleroderma

Abstract Date Presented 4/17/2015 In this study, we describe the Valued Life Activities Scale to measure importance and difficulty with occupations in persons with scleroderma and factors related to difficulty with performance. Obligatory occupations (e.g., self-care) were more important, but committed occupations (e.g., housework) were more difficult.

Whenmightisn’t right: the impact of muscle weakness on physical function in systemic lupus erythematosus

Pascal, the renowned 17th century French philosopher and mathematician, was admittedly concerned less with physical weakness, than with spiritual or moral weakness when he penned this statement of surprise. Nevertheless, the sense of astonishment underlying his words remains apropos to our discussion of physical weakness among individuals with systemic lupus erythematosus (SLE). Reduced physical functioning is common among individuals with SLE and is frequently associated with significantly reduced health-related quality of life [1,2]. Differences in body composition, and in particular differences in muscle strength, represent an important etiology of reduced physical functioning among individuals with SLE. What is truly surprising is that despite the considerable burden of physical disability and muscle weakness in SLE, published data addressing these relationships remain limited. There exists, however, a body of literature examining relationships between body composition, muscle strength and physical disability among other chronic conditions, both rheumatic and nonrheumatic. Among elders and individuals with osteoarthritis (OA), muscle strength and muscle mass (both regional and total body muscle mass) are inversely related to physical disability [3,4]. However, muscle strength is more closely related to the degree of disability than is muscle mass among the elderly [5]. Among individuals with rheumatoid arthritis (RA), similar relationships exist between muscle mass, muscle strength and physical disability [6]; and, similar to in OA, in RA measures related to muscle function are more strongly associated with differences in physical functioning than are measures of muscle mass [7]. Taken together, these observations suggest that muscle strength makes an important contribution to an individual’s physical functioning in various populations. Until recently it was not known whether similar relationships exist among individuals with SLE. Our group recently demonstrated that among women with SLE muscle strength is directly associated with differences in physical functioning even when adjusting for differences in muscle mass; and differences in muscle strength at baseline predict changes in physical functioning 2 years later [8,9]. In this cohort of adult women with SLE, reduced lower extremity muscle strength (measured by knee strength and chair stand time) but not reduced muscle mass was associated with reduced self-reported physical functioning on the SF-36 Physical Functioning subscale and on the Valued Life Activities assessment, when adjusting for covariates such as disease activity, medication use and depression. Reduced knee strength also predicted significant decreases in physical functioning approximately 2 years later, as measured by the Short Physical Performance Battery When might isn’t right: the impact of muscle weakness on physical function in systemic lupus erythematosus

Pain and difficulties performing valued life activities in women and men with rheumatoid arthritis.

This study aimed to examine the difficulties with performing valued life activities in relation to pain intensity in women and men with rheumatoid arthritis (RA). In total, 737 persons with RA (73 % women) from three rheumatology units in Sweden responded to a questionnaire measuring performance of 33 valued life activities and self-rated pain. The relationships between performance of valued life activities (VLAs) and pain (measured by visual analogue scale (VAS)) were analysed based on gender. Multiple linear regression analyses were conducted with the total VLA score as dependent variable. Women reported more pain and difficulties in performing valued life activities than men. Across genders, 85 % reported at least one valued life activity affected by RA. Significantly more women than men encountered difficulties in performing some activities such as cooking, gardening and meeting new people. Women reported higher pain intensity (35 mm) than men (31 mm). Almost all 33 difficulty ratings for valued life activities were higher among persons with high pain (>40 mm) than persons with lower pain. Difficulty ratings for valued life activities correlated positively with pain in persons with lower pain, but not among those with high pain. The results highlight the importance of addressing pain, especially among women with RA, as they reported pain to impact on their valued life activities. Interestingly, this was evident also in women with lower levels of pain.

Participation in activities of daily living can reduce loneliness in older adults.

Sir, We agreed with Tiwari that loneliness among older adults become significant public health issue.[1] In his guest editorial, Tiwari mention three types of loneliness situational, developmental and internal loneliness.[1] We believe the ability to perform activities of daily living (ADL) can help to reduce the chances of loneliness. For healthy ageing and to maintain older adults mobile ADL activities plays an essential role.[2] They focus more on ADL activities compare to any other work because it is a common activity people used to do throughout their lives to fulfill their time and give meaning of their life.[3] Activities that a person value encourage to participate and give help to look forward in daily life.[3] Valued life activities categorized as obligatory, committed and discretionary activities[3] among these obligatory and committed activity are purely ADL activities. Obligatory activities include activities necessary for survival basically known as personal ADL[34] or basic ADL[4] such as bathing, showering, bowel and bladder management, dressing, eating, feeding functional mobility, personal device care, personal hygiene and grooming, sexual activity, toilet hygiene.[34] Committed activities includes social role, family care and family responsibility known[4] as instrumental ADL such as care of others, care of pets, child rearing, communication management, community mobility, functional management, health management and maintenance, home establishment and management, meal preparation and clean-up, religious observance, safety and emergency maintenance, shopping.[4] When older persons able to perform all these ADL task independently with or without the help of assistive devices, surely it gives them satisfaction and felling of independence.[2] Which surely help them to reduced loneliness by providing the confidence and self-esteem. It also helps them to occupy their time by doing those activities in regular basis and help to integrate with social life. However, older adults showed age related decline with tasks even when those task are familiar, practiced and environmentally valid.[5] It is also applicable to their ADL activities also. Older adults should perform ADL as many as possible to maintain their activeness when they are not able to increase their activity level according to require guidelines within their abilities and depend upon health condition.[2] Ability to perform any ADL activity depends on client factors, performance skills, pattern of performance, and demand of that activity, context, and the environment.[4] Without detail evaluation of all aspect, it is a difficult task to address ADL related issues in elderly. Evaluation and implementation of the intervention is individualistic in nature, which makes this job a specialized one. We occupational therapist do ADL evaluation and intervention in our everyday practice because occupational therapy profession uses the term occupation to capture the breadth and meaning of everyday activity of an individual.[4] Though a multidisciplinary team approach is require to prevent loneliness where occupational therapist can play an important role to make older adults independent in their ADL activities by modifying the demand, context, environment and pattern of the activity. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.