A new study by researchers at the National Institute on Aging (NIA) demonstrates that a small number of diseases and conditions that can lead to hospitalization-- stroke, hip fracture, congestive heart failure, pneumonia, coronary heart disease, diabetes, and dehydration -- are responsible for a large proportion of severe disability in older people. Targeting these conditions for intensive treatment and rehabilitation, the researchers say, could help reduce disability among a substantial number of older people and improve their ability to function independently.
Appearing in the March 5, 1997, Journal of the American Medical Association *, the study employs a new way of looking at disability. People who become disabled rather suddenly, compared with those whose disability comes on more slowly, are much more likely to be hospitalized for the seven conditions. By looking at the pace of disability and related hospitalizations in this way, the researchers were able to pinpoint the diagnoses for which aggressive treatment might be most beneficial.
Other research has suggested that other variables, not age, are related to the success of treatments and therapies. The new analysis finds that the very elderly, people age 85 and older, with sudden, severe disability, were treated less intensively in the hospital than their younger counterparts. This latest finding, the researchers say, coupled with the earlier data, suggests that physicians are improperly using age as a criterion for treatment.
The study was conducted by Luigi Ferrucci, M.D., Jack Guralnik, M.D., Ph.D., Marco Pahor, M.D., Maria Chiara Corti, M.D., M.H.S., and Richard Havlik, M.D., M.P.H. of the NIA's Epidemiology, Demography, and Biometry Program. Ferrucci, Pahor, and Corti worked on the project as visiting scientists.
"Our analysis of disability and hospitalization is unique from other studies. We looked at changes in functional status of people prior to when their severe disability occurred and concentrated on evaluating hospital stays that took place in the year when their severe disability developed," says Guralnik. "Studying the pace of disability should now give doctors a better way of looking at preventing disability. We now have a picture of how severe disability evolves."
The study population included 6,070 people who were part of the Established Populations for Epidemiologic Studies of the Elderly, or EPESE, longitudinal studies of people 65 and older at three sites across the U.S. Participants were classified based on the severity of their disability.
People in need of help or unable to perform three or more fairly common activities of daily living, such as walking, bathing, and dressing, were classified as severely disabled.
In a novel approach, the participants were then divided into categories reflecting the pace of their disability. 'Catastrophic' disability occurred in people whose decline was very rapid while people with 'progressive' disability lost abilities more gradually, over a longer period of time.
The researchers compared degrees of disability and the course of disability with hospitalizations and nursing home admissions. Overall, for any diagnosis, 72 percent of people with catastrophic disability were hospitalized in the year in which they became disabled while about half of those with progressive disability were hospitalized in their year of disability. Breaking down the hospitalizations even further, Guralnik and colleagues found that about half of the hospitalizations for those with catastrophic disability could be attributed to only a few conditions -- stroke, hip fracture, congestive heart failure, pneumonia, coronary heart disease, and cancer. About one-fourth of the hospitalizations for more progressively disabled people were related to a similarly small number of conditions, in this case stroke, hip fracture, congestive heart failure, pneumonia, diabetes, and dehydration.
Once in the hospital, the researchers found the oldest patients received less intensive care. The researchers' examination of Medicare charges showed that advancing age was associated with quicker discharge and lower Medicare charges for each hospital admission, reflecting less intensive treatment. Guralnik pointed to earlier research by the same group which found that survival after disability is not related to age. Medical technologies used in intensive care wards, pharmacological treatments, surgery, and rehabilitation procedures have been shown to have similar benefits for older people as they do for younger people for survival and quality of life.
Advanced age, in and of itself, should not be used, therefore, as a basis for determining how aggressively an older person should be treated, the study's authors say. The research points to the potential need to make use of various procedures more frequently and intensively in older patients and that the time of hospitalization may be most opportune for reducing disability.
The NIA, a component of the National Institutes of Health, leads the Federal effort supporting basic, clinical, epidemiological, and social research on aging and the special needs of older people.