Trends in Functional Status and Disability among the Elderly

Ellen Kramarow

Jennifer Akerblom

NCHS Data Users Conference

July 2004

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESCenters for Disease Control and PreventionNational Center for Health Statistics

Overview

Disability and Functioning

•Definitions

•Trends

Data Warehouse on Trends in Health and Aging

•Examples

Definitions

Conceptual Frameworks (Nagi, IOM, WHO)

•Pathology

•Impairment

•Functional Limitation

•Disability

Definitions

Disability is a complex concept

•Intersection of individual’s capacity with environment

•Measurement in surveys does not necessarily capture all aspects of concept

Definitions

Disability Measurement

•Self-report vs. performance measures

•Survey design considerations (e.g., institutionalized vs. noninstitutionalized, age groups, cross section vs. panel, self-report vs. proxy)

Definitions

Disability Measurement

•Activities of Daily Living (ADL)

•Instrumental Activities of Daily Living (IADL)

•Physical functioning (aka Nagi items)

Definitions

Disability Measurement

•Question wording •Difficulty•Needs/receives help•Ability to perform with/without

help or equipment

Trends

Recent review in JAMA (Freedman et al., 2002)

•Declines in IADL limitations

•Declines in physical functioning (Nagi) limitations

•Mixed evidence on ADLs (forthcoming paper shows decline in some measures from mid-1990s)

Trends

Data Warehouse on Trends in Health and Aging

• A collection of data tables providing information on trends of health and health care use by older Americans.  Viewable online or with Beyond 20/20 software.

• Supported with funding from the National Institute on Aging (NIA)

• http://www.cdc.gov/nchs/agingact.htm

Medicare Current Beneficiary Survey (MCBS)

• Began in 1991

• Survey sample:

• N = 12,000 (target sample size)

• community and facility dwelling Medicare beneficiaries

• Questions include:

• health care use and cost

• sociodemographic characteristics

• health status

• physical functioning

MCBS and ADLs

•Question:

•Because of a health or physical problem, do you have any difficulty bathing/showering, dressing, eating, getting in/out of a bed/chair, walking, or using the toilet?

Limitation of Activity: Any Difficulty Performing ADLs, MCBS 1992-2002

0

5

10

15

20

25

30

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Year

Per

cen

t (a

ge-

adju

sted

)

Bathing/Showering Dressing Eating

Getting in/out of bed/chairs Walking Using the toilet

Community Residents Age 65 and over

Difficulty Performing ADL - Bathing/Showering - by Race, MCBS 1992-2002, Community Residents Age 65 and over

0

5

10

15

20

25

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Year

Pe

rce

nt

(ag

e-a

dju

ste

d)

White non-Hispanic Black non-Hispanic Hispanic

Limitation of Activity: Difficulty Performing Activities of Daily Living, by Age,

Residence, Sex, Race and Ethnicity. MCBS, 1992-2002

• Among all individuals age >=65:

• Decrease in reported ADL limitations between 1992-2002

• Among individuals living in a facility:

• Increasing trend in reported difficulty eating and/or using the toilet

National Health Interview Survey(NHIS)

• Initiated in 1957

• Surveys the civilian non-institutionalized population, N = approx. 100,000 persons from about 43,000 households

• Collects information on the amount, distribution and effects of illness and disability

• Survey redesigned in 1997

NHIS and ADLs

•Question:• Because of a physical, mental, or

emotional problem, do you need the help of other persons with personal care needs? If yes, do you need the help of other persons with bathing, dressing, eating, getting in/out of bed/chair, using the toilet, including getting to the toilet, and getting around inside the home?

Needing Help with Activities of Daily Living, NHIS, 1997-2001 Noninstitutionalized Persons, Age 65 and over

0

1

2

3

4

5

6

7

1997 1998 1999 2000 2001

Year

Per

cen

t (a

ge-

adju

sted

)

Bathing/Showering Dressing Eating

Getting in/out of bed/chair Using/getting to toilet Getting around inside home

Needing Help with Activities of Daily Living - Bathing/Showering, NHIS 1997-2001 Noninstitutionalized Persons Age 65 and over

0

1

2

3

4

5

6

7

8

1997 1998 1999 2000 2001

Per

cen

t (a

ge-

adju

sted

)

BothsexesMale

Female

Needing Help with ADLs by Age, Sex, Race, and Hispanic Origin. NHIS, 1997-2001

• From 1997-2001, a decreasing trend in reported need for help with bathing/showering was observed

• No significant change occurred in the percentage of people reporting they need help with other ADLs

Limitations in Bathing, Noninstitutionalized Persons Age 65 and over: MCBS and NHIS

0

2

4

6

8

10

12

14

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Year

Per

cen

t (a

ge-

adju

sted

)

MCBS

NHIS

Any difficulty

Needs help

MCBS and Physical Functioning

• Question:

• How much difficulty, if any, do you have stooping, lifting, reaching, grasping, and walking a quarter mile?

• Response Options:

• No difficulty at all, A little difficulty, Some difficulty, A lot of difficulty, Not able to do, Refused, Don’t know

Any Difficulty in Physical Functioning - Community Residents Age 65 and over, MCBS 1992-2002

0

10

20

30

40

50

60

70

80

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Years

Pe

rce

nt

(ag

e a

dju

ste

d)

Stooping Lifting Reaching Grasping Walking

Limitation of Activity: Difficulty in Physical Functioning by Age, Residence, Sex and Race. MCBS, 1992-2002

• Community dwelling individuals reported:

• Increased difficulty stooping

• Decreased difficulty lifting, reaching and grasping

• Facility dwelling individuals reported:

• Increased difficulty lifting

NHIS and Physical Functioning

• Question:

• By yourself, without using any special equipment, how difficult is it for you to walk a quarter mile, climb, stand, sit, stoop, reach, grasp, carry, and push?

• Response Options:

• Not at all difficult, Only a little difficult, Somewhat difficult, Very difficult, Can’t do at all, Do not do this activity

Any Difficulty in Physical Functioning, Noninstitutionalized Persons Age 65 and over, NHIS 1997-2002

0

10

20

30

40

50

60

70

1997-1998 1998-1999 1999-2000 2000-2001 2001-2002

Years

Per

cen

t (a

ge-

adju

sted

)

Walking Climbing Standing Sitting Stooping

Reaching Grasping Carrying Pushing Any limitation

Any Difficulty in Physical Functioning by Age, Sex, Race, and Hispanic Origin. NHIS, 1997-2002

• 65% of the respondents reported ‘any difficulty’ with at least 1 of 9 physical tasks

• Percentage reporting ‘any difficulty’ has remained constant from 1997-2002

Any Difficulty with Selected Physical Functioning Measures Among Noninstitutionalized Persons Age 65

and over in MCBS and NHIS

0

10

20

30

40

50

60

70

80

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Years

Per

cen

t (a

ge-

adju

sted

)

MCBS - Stooping

MCBS - Walking

NHIS - Stooping

NHIS - Walking

Discrepancy in Stooping Measure

• MCBS asks about “stooping, crouching, or kneeling”

• NHIS asks about “stooping, bending, or kneeling”

• Percent “unable” to perform stooping is similar in both surveys

• Unclear why estimates are different

Summary

• MCBS data from 1990s show decline in ADL limitation among noninstitutionalized older persons.

• NHIS shows a decline in percent needing help with bathing/showering only from 1997 to 2001.

• For many items, no change seen during time period covered by NHIS.

Summary

• MCBS shows declining percent with difficulty in lifting, reaching, and grasping. Stooping measure is a puzzle.

• Data on institutionalized generally show increase in disability.

Summary

• A lot of data on disability and functioning among the elderly are available.

• Estimates across sources may differ because of differences in question wording, sample design, and other factors.

• Making sense of the data takes work and attention to detail.