Disability in older people

See also the separate Prevention of Falls in the Elderly and Prescribing for the Older Patient articles.

The UK population is ageing. Disability in old age is frequent and lowers quality of life. Both mental and physical disability predispose to admission to hospital, need for residential care, and premature death. Helping to combat disability in the elderly can improve quality of life.

Some definitions

The World Health Organization has defined disability as the following¹ :

"Disability is an umbrella term, covering impairments, activity limitations, and participation restrictions. An impairment is a problem in body function or structure; an activity limitation is a difficulty encountered by an individual in executing a task or action; while a participation restriction is a problem experienced by an individual in involvement in life situations. Thus disability is a complex phenomenon, reflecting an interaction between features of a person's body and features of the society in which he or she lives."

Activities of daily living (ADLs) include personal-care activities such as eating, bathing, dressing, and using the toilet.

Instrumental activities of daily living (IADLs) include household chores, shopping, managing medication, climbing stairs, public transport, finances and walking. They can be affected by cognitive impairment.

Frailty in the elderly is described as a state of global impairment of physiological reserves involving multiple organ systems. Frailty manifests as increased vulnerability, impaired capability to withstand intrinsic and environmental stressors, and limited capacity to maintain physiological and psychosocial homeostasis. Frailty is found in 20-30% of the elderly population aged over 75 years and increases with advancing age. It is associated with long-term adverse health-related outcomes such as increased risk of geriatric syndromes, dependency, disability, hospitalisation, institutional placement, and mortality² .

Epidemiology

In 2018, the Office for National Statistics (ONS) estimated that there will be an increasing number of older people in the UK; the proportion aged 85 years and over was projected to almost double over the subsequent 25 years³ . The ONS normally publishes an updated projection every two years. However, it did not do so in 2020 as it wanted to incorporate figures from the 2021 census. Clearly, the impact of the COVID-19 pandemic will have some effect on the projection.

An Age UK analysis found that the restrictions on physical activity imposed by the COVID-19 pandemic resulted in a worsening of disability in those surveyed. It found that 1.2 million older people aged 60+ in the UK who had difficulty walking up and down the stairs before restrictions, reported that this activity had become even more difficult for them since then, while 1.45 million of the 60+ population currently had difficulty walking short distances outside when previously this did not pose problems for them at all. 3.8 million (23%) older people's ability to do everyday activities had worsened since restrictions were imposed⁴ .

Managing older people's health effectively will be important.

Disability causes (aetiology)

According to Canadian research, five types of chronic illness contribute largely to disability in people aged over 65 years⁵ :

• Foot problems

• Arthritis

• Cognitive impairment

• Heart problems

• Vision

Other common or important problems include:

• Hearing impairment.

• Chronic respiratory and cardiovascular disease such as chronic obstructive pulmonary disease (COPD), chronic heart failure, coronary heart disease and cerebrovascular disease.

• Falls and hip fracture⁶ .

In frail elderly people, a marked decline in physical and mental function can result from apparently small insults. This has been called the 'domino' effect, with a small initial insult leading to a cascade of adverse events⁷ .

Disability risk factors

Frailty in the elderly may be due to a combination of predisposing factors (early childhood development and lifestyle), followed by contributing factors such as physical inactivity, chronic disease, and anorexia/malnutrition in later adulthood⁷ .

One review in Brazil found that the main risk factors for functional disability in elderly people in the community were lack of schooling, rented housing, chronic diseases, arthritis, diabetes, visual impairment, obesity, poor self-perceived health, cognitive impairment, depression, slow gait, sedentary lifestyle, tiredness while performing daily activities, and limited diversity in social relations⁸ . These factors may be influenced by access to healthcare and the cost of healthcare in different countries.

The normal ageing process

Age is associated with a 1-2% decline in functional ability per year. Sedentary behaviour accelerates the loss of performance⁹ . Age-associated physiological changes include:

• Changes in body composition - reduction in muscle bulk and lean body mass, known as sarcopenia¹⁰ . Body fat may increase.

• Reduction in bone mass and strength with increased risk of fracture; osteoarthritic changes in joints.

• Reduction in blood volume, reduced tolerance of tachycardia; reduced ability to control blood pressure with postural change.

• Reduction in ventilatory capacity.

• Reduction in kidney function; impaired thirst mechanisms which increase susceptibility to dehydration.

• Reduced sensitivity to vitamin D and subsequent reduction in calcium absorption.

• Reduced motility of the large bowel; reduced hepatic mass and blood flow (which may affect hepatic metabolism of drugs).

• Nervous system changes, including reduction in cortical function and reduced motor and sensory peripheral nerve function; changes in autonomic function, including control of heart rate and temperature regulation (failure of normal response mechanisms to hot and cold).

• Reduced elasticity of the eye's lens; high tone hearing impairment.

Comorbidities

People aged 70 years and over often have have one or more chronic conditions. Comorbidities may contribute to disability - for example:

• Stroke can lead to weakness, co-ordination problems, locomotor difficulties and problems of communication and continence.

• Coronary heart disease may lead to heart failure, angina or myocardial infarction.

• Diabetes - complications which can contribute to disability in a variety of ways (eg, the contribution of diabetic neuropathy to poor mobility) may be underestimated.

• Alzheimer's disease is the most common neurodegenerative disease. By the age of 85 years, 30% of the population has Alzheimer's disease.

• Urinary problems can be disabling, particularly if causing incontinence.

• Depression is often the result of disability but it also makes disability worse. 10-15% of people aged over 65 years living at home are depressed.

• Visual loss is associated with an increased risk of falling.

• Hearing and visual impairment increase the risk of social isolation and resulting depression.

• Falls are associated with injury, pain and loss of function. The prevalence of osteoporosis in the elderly population means that falls are more likely to result in fractures.

Assessment

The British Geriatric Society (BGS) has provided a useful toolkit to assess elderly people in primary care. This assessment is called a Comprehensive Geriatric Assessment (CGA). It includes evaluation of¹¹ :

• Physical assessment.

• Functional, social and environmental assessment.

• Psychological components.

• Medication review.

Assessment by a specialist geriatrician and/or a multidisciplinary team specialising in elderly care can be useful.

A marked decline in function can be due to relatively small physiological insults, which may result in a frail older person being wrongly labelled as 'unable to cope'. Bear in mind that early comprehensive geriatric assessment and appropriate treatment may enable such patients to regain lost function.

Validated tools for assessment of disability or needs in elderly people include:

• Barthel's Index¹² .

• Nottingham Extended Activities of Daily Living Scale¹³ .

• The Timed Up and Go Test (TUGT)¹⁴ .
  

Disability treatment and management

General points^{7 11}

Important aspects of management

• Treatment of unstable medical conditions and any treatable problems contributing to the disability.

• Reviewing drug treatment (including polypharmacy).

• Early mobilisation.

• Nutritional support.

• Comprehensive rehabilitation.

Who should be involved in management?

• A multidisciplinary approach can be helpful. This has been shown to be advantageous in developing a proactive approach to assessments and reducing the number of unplanned hospital admissions¹¹ . Geriatric day hospitals have been shown to be beneficial in providing care to elderly people with functional decline, although a Cochrane review found they may not have any clear advantage over other forms of comprehensive elderly medical services¹⁵ .

• Admission avoidance 'hospital at home' schemes with the option of transfer to hospital, may provide an effective alternative to inpatient care for a select group of elderly patients requiring hospital admission. However, a Cochrane study found that the evidence is limited ¹⁶ .

• 'Case management' by community matrons is a development in the care of elderly patients and those with long-term conditions. A review of this strategy concluded that this provision is at an early stage of development, and needs to develop effective links with a range of local services¹⁷ . The financial viability of this service is not clear¹⁸ .

Aspects of management

Treat contributing causes
Do not assume that age-related disability is untreatable. Look for and treat contributing problems (where feasible), such as:

• Uncontrolled cardiac, respiratory or metabolic disease - eg, heart failure, hypothyroidism.

• Reversible causes of hearing loss - eg, wax.

• Potentially treatable neurological disease - eg, tumours.

Drug treatment

• Medication can contribute to both the problem of disability and to the solution.

• Polypharmacy and increased susceptibility to drug side-effects are some of the issues surrounding medication in older people. See the separate Prescribing for the Older Patient article which discusses this topic in detail.

• Vitamin D deficiency should be recognised and treated in the elderly. The Department of Health has recommended that people over the age of 65 years take vitamin D supplements.

Surgical treatment

• Age alone is not a contra-indication for surgery.

• Operations such as joint replacement, cataract surgery and surgery for prostatic hypertrophy are frequently performed on the elderly to reduce disability.

Provision of aids and appliances

• Occupational therapy and the provision of aids can improve the quality of life. Home adjustments such as grip rails, stair lifts and removal of dangers such as loose carpets or inappropriate footwear can be helpful.

• Aids should be used to make the most of impaired vision or hearing.

• Glasses, low-vision aids such as magnifying glasses, large-print materials, talking clocks and watches, telephones with large numbers, audio books, and safety measures, such as raised-dot dials on kitchen equipment, may all be helpful.

• Hearing aids can greatly improve quality of life.

• Adapted safety devices may be needed (eg, flashing light on telephone or smoke alarm).

Pain management
A paper discussing chronic pain in elderly people suggests that persistent pain in elderly patients is not simply a chronologically older version of younger pain¹⁹ . They suggest that interventions such as a 'mindfulness-based stress reduction programme' can be helpful. This is supported by brain imaging studies, which demonstrate that regulation of pain by cognitive and medidative therapies can alter the functioning of brain regions²⁰ .

Appropriate exercise can be part of pain management in some conditions - eg, osteoarthritis²¹ .

Social and environmental interventions
These may reduce the impact of the disability - for example:

• Financial support - eg, access to benefits and grants.

• Social support - eg, day centres, social activities and befriending.

• Housing support - appropriate accommodation can support independence and increase functional ability.

Disability prevention

There is strong evidence of benefit to older people from increasing physical activity, improved diet and nutrition and immunisation and management programmes for influenza.

Exercise

Exercise has some benefits in frail older people²² . Adapted exercise is beneficial for strength, mobility and balance and may reduce the risk of falls. This applies even to frail older people. Indirectly, physical activity may also increase well-being, social activity and mental health.

Evidence on the role of exercise in preventing disability
In terms of preventing disability, some trials involving physical exercise interventions reported positive outcomes for disability. However, differences between the trials can make it difficult to review the evidence or to make precise recommendations^{23 24} .

A review of disability from hip fracture suggested physical activity can protect against the risk of hip fracture among community-dwelling older adults⁶ . This may be via increased levels of vitamin D, or through the improvement of bone quality.

One editorial proposes 'assertive screening', using a single question to identify middle-aged and elderly people who are sedentary. These people could be invited to participate in lifestyle interventions including a prescription for exercise. It is suggested that a single question about a fall in the previous year is a method of identifying those who will benefit most²⁵ .

How much exercise?
The UK Chief Medical Officers' Guidelines advise²⁶ :

• Older adults should be undertaking activities designed to improve or maintain muscle strength, balance and flexibility on at least two days a week.

• Each week older adults should aim to accumulate at least 150 minutes of moderate-intensity aerobic activity, building up gradually from current levels. Those who are already regularly active can achieve these benefits through 75 minutes of vigorous-intensity activity, or a combination of moderate and vigorous activity, to achieve greater benefits. Weight-bearing activities help to maintain bone health.

Nutrition²⁷

• Elderly people have relatively more body fat and less lean body mass, resulting in lower metabolic rates. Therefore, calorie needs are reduced, so the diet needs proportionately more protein, essential fats and micronutrients.

• Avoiding obesity is also beneficial.

• Aim to meet minimum nutritional requirements, provide adequate dietary fibre and address specific disease risks such as cardiovascular disease, stroke, diabetes and osteoporosis.

• Oral health and provision of dental treatment are important.

• Hospital nutrition - Age UK has campaigned for greater awareness of the problem of malnutrition in hospitalised elderly patients. It advocates that organisations across sectors and settings must ensure that they have robust processes in place for raising awareness of risk, prevention, recognition, measuring, monitoring and treatment of malnourishment. This must include providing help and support with eating and drinking for people when they need it .

• Folic acid ± vitamin B12 has been suggested as possibly benefiting cognitive function in elderly people. However, a Cochrane review concluded that there is no consistent evidence either way, and more research is needed²⁸ .

Screening and case finding¹¹

Are health checks useful?
There is little evidence to support the use of random health checks in the elderly. However, there is evidence that a CGA as described above is effective in reducing mortality and improving independence for older people admitted to hospital as an emergency compared to those receiving usual medical care. Furthermore, in community settings, the evidence suggests that complex interventions in people with frailty can reduce hospital admission and the risk of readmission in those recently discharged.

The BGS advocates that a CGA should be performed:

• When an older person presents to their GP with one or more obvious frailty syndromes (eg, falls, confusion, reduced mobility and increasing incontinence).

• When a GP or community team learns of an incident which implies frailty in an individual - eg if an ambulance is called after a fall.

• After discharge from hospital when presenting with a frailty syndrome (eg, fall, reduced mobility, delirium).

• In care homes - most residents will have frailty.

• For any patient at moderate risk, as identified by frailty risk stratification systems (some of which are built into GP clinical software programmes).

The BGS acknowledges that this represents a considerable workload, especially since a significant proportion of the target population will require home visiting, but suggests that such a service could be provided by multi-disciplinary teams (including social services) and built into commissioning plans.

Preventing falls and osteoporosis

See the separate Prevention of Falls in the Elderly and Osteoporosis Risk Assessment and Primary Prevention articles.