Future Directions for the Demography of Aging Proceedings of a Workshop (2018) / Chapter Skim
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10 The Demography of Late-Life Disability - Vicki A. Freedman
10 The Demography of Late-Life Disability - Vicki A. Freedman
Pages 269-306
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From page 269... ...
. One in four older adults successfully accommodates losses in physical capacity and continues to carry out daily activities without difficulty or assistance (Freedman and Spillman, 2014b)
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The third section provides a broad portrait of late-life disability, drawing upon the 2015 round of the National Health and Aging Trends Study (NHATS) , an annual study of U.S.
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. In this chapter, the term "disability" is used broadly to include four domains: impairments in body functions or structures; reduced physical, sensory, or cognitive functioning; difficulty carrying out self-care or household activities by oneself, receipt of help, or use of compensatory strategies that signal the need for help; and restrictions in participation in productive, social, or community life.
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Functional limitation is defined at the level of the whole person and refers to limitations in physical or mental actions. Finally, disability refers to the final stage in the process: the inability to carry out a socially defined role, such as work or self-care or household activities.
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health conditions may emerge as a consequence of the disablement process. The NHATS Framework Begun in 2011 with funding from the National Institute on Aging, NHATS is a national panel survey of Medicare beneficiaries ages 65 and older that is specifically designed to promote research to reduce disability, maximize independent functioning, and enhance quality of life at older ages.
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. The main pathway recognizes that health conditions influence body functions and structures, which in turn influence activities and participation.
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For instance, it can be used to test psychological and social theories linking compensatory strategies to qualityof-life outcomes such as continued participation in activities of value and maintenance of subjective well-being. It can also be used to test hypotheses about behavioral responses to declines in capacity -- for instance, the circumstances under which preclinical disability occurs before reports of difficulty, or the pathways from intrinsic changes in activity performance (e.g., more slowly, less often)
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, making it possible for the first time to examine for a national sample annual changes in physical capacity, compensatory strategies, activity limitations, participation restrictions, and consequences such as unmet need. Both classical and modern approaches to test development have been used to evaluate the protocol (Freedman et al., 2011; Kasper et al., 2017)
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. NHATS measures physical capacity using an expanded set of selfreported measures adapted from Nagi (Freedman et al., 2011)
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A score drawing upon both self-reports and performance tests provides better measurement precision across the full spectrum and appears better suited than either approach alone for studying age-related changes in physical capacity. The Physical, Service, and Technological Environments For many years, measures of the home environment, developed primarily for clinical interventions (Gitlin, 2003)
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. A PORTRAIT OF LATE-LIFE DISABLITY IN THE UNITED STATES This section provides a snapshot of late-life disability in the United States for several major demographic groups and highlights the distinctive disadvantage of minority women.
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Other studies suggest that successful accommodation is more likely for those with more children and those living in homes with environmental features already installed and that those who successfully accommodate report well-being on par with, and participation restrictions only slightly below, those who are fully able to carry out activities ( reedman F et al., 2014, 2017)
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Age gradients for four of the measures (low physical capacity, poor vision, poor hearing, and probable dementia) and a summary measure of poor physical, sensory, or cognitive capacity are displayed in Figure 10-2.
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SOURCE: Data from National Health and Aging Trends Study.
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THE DEMOGRAPHY OF LATE-LIFE DISABILITY 283 Household Activities Difficulty Help for Health/ Fully Able Less Often by Oneself Functioning Reasons 62.2 8.5 16.1 13.2 62.8 6.6 15.5 15.1 55.2 8.7 15.0 21.2 43.0 8.6 13.2 35.2 32.0 7.0 12.8 48.2 15.7 3.3 8.1 73.0 62.2 5.4 14.7 17.7 46.9 9.4 14.6 29.1 55.7 7.5 14.8 22.0 43.3 9.7 14.6 32.4 48.4 7.5 13.7 30.4 42.1 9.9 16.1 31.9 65.3 5.9 14.2 14.6 56.1 7.6 13.2 23.1 40.8 8.2 13.8 37.3 43.1 6.7 13.7 36.6 49.2 9.6 14.7 26.6 59.0 7.8 14.7 18.5 62.8 6.4 14.8 16.0 63.5 6.9 17.8 11.8 53.7 7.6 14.7 24.0
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. SOURCE: Data from National Health and Aging Trends Study.
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THE DEMOGRAPHY OF LATE-LIFE DISABILITY 285 Sensory Cognitive % Poor % Poor % Probable % Possible Vision Hearing Dementia Dementia 6.5 9.5 2.6 3.5 6.4 8.7 3.9 3.4 8.3 10.1 8.0 5.3 9.1 16.3 15.9 7.9 15.5 20.0 23.3 11.9 23.8 33.4 36.3 15.1 7.0 13.8 8.4 5.3 10.0 10.9 9.7 6.0 7.3 11.7 8.1 4.6 12.1 6.6 12.3 10.0 14.2 18.1 13.1 9.4 9.7 12.5 13.2 7.8 5.6 10.2 4.5 3.4 10.0 15.9 8.3 4.9 15.3 15.5 15.4 8.6 17.9 20.7 15.9 11.4 9.7 13.4 9.3 6.0 6.4 10.0 4.1 3.3 4.9 9.7 4.9 2.3 3.7 6.5 2.9 3.1 8.7 12.2 9.1 5.7
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NOTES: N = 7,859; nursing home residents are omitted for poor hearing and poor vision and summary category of poor capacity (N = 7,499)
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Participation Restrictions and Unmet Need The negative consequences of living with activity limitations can be substantial for some older adults (see Table 10-5, which focuses on older adults in settings other than nursing homes)
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. SOURCE: Data from National Health and Aging Trends Study.
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THE DEMOGRAPHY OF LATE-LIFE DISABILITY 289 Service Environment Assisted/ Retirement/ Nursing Home Independent Living Sr. Housing Community 1.1 1.0 3.5 94.4 0.8 1.7 5.7 91.7 1.4 3.0 7.1 88.5 3.9 7.7 7.8 80.6 6.1 13.0 6.7 74.2 13.7 22.3 6.4 57.5 1.5 3.2 5.1 90.3 3.4 5.6 6.2 84.8 2.6 4.8 5.9 86.7 3.7 3.4 5.5 87.5 1.6 3.6 4.9 89.9 8.0 11.3 9.4 71.3 0.0 1.9 5.1 93.0 0.0 0.0 0.7 99.3 0.0 0.8 2.9 96.3 - 4.9 6.6 88.5 - 5.1 5.3 89.6 - 4.3 6.2 89.4 - 4.9 5.4 89.7 - 3.7 5.9 90.4 2.5 4.5 5.7 87.2
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. SOURCE: Data from National Health and Aging Trends Study.
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. SOURCE: Data from National Health and Aging Trends Study.
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. SOURCE: Data from National Health and Aging Trends Study.
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Older minority women have about two to three times the risk of nonHispanic White men of receiving assistance with self-care, mobility, or household activities or of having low physical capacity, poor vision, or probable d ementia. They are also much less likely to successfully accommodate with assistive devices to carry out their self-care and mobility activities.
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Occasionally, studies will emphasize differences in trajectories by indicators of earlier stages of the disablement process -- that is, by the presence of a particular health condition (Chiu and Wray, 2011) or functional limitation (Martin et al., 2017)
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The other set has focused on active life expectancy, which combines agespecific disability and mortality rates. Several excellent reviews have been published in recent years (Beltrán-Sánchez et al., 2015; Crimmins, 2015; Martin et al., 2010; Wolf, 2016)
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. There were no significant shifts in expected years lived in any of the other categories of activity limitations, nor were there significant changes in years lived with low physical capacity (5.5 versus 5.4 years)
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Statistical advances have also furthered investigations into late-life disability trajectories. The leading edge of the Baby Boom generation began to turn age 65 in 2011 and over the next decade will reach ages 65–82.
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and 7,859 (2015) ; nursing home residents are omitted for poor vision and hearing, N = 7,609 (2011)
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THE DEMOGRAPHY OF LATE-LIFE DISABILITY 299 2015 Expected Years 65–69 70–74 75–79 80–84 85–89 ≥ 90 Lived 41.7 36.2 25.5 16.9 9.4 4.2 5.3*
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Projection models can now be built that recognize not only biological but also environmental and behavioral underpinnings of the disablement process. They can now also recognize the shifting relationships among disease, capacity, accommodations, limitations, and outcomes such as participation restrictions and unmet need.
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. Active life expectancy in the older U.S.
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. A short physical performance battery assessing lower extremity function: Association with self-reported disability and prediction of mortality and nursing home admission.
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. Construction of Performance-based Summary Measures of Physical Capacity in the National Health and Aging Trends Study (NHATS Technical Paper No.
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Milbank Memorial Fund Quarterly: Health and Society, 60, 183–244. Manton, K.G., and Gu, X
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. Cohort differences and chronic disease profiles of dif ferential disability trajectories.
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