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We wish to acknowledge the excellent work of the editors and authors of this book and their timely publication of these data. We are especially pleased that the text and tables in this monograph will be available on the Internet for use by local and global audiences. We would particularly like to express appreciation to Drs. Linda Fried and Jack Guralnik, who chaired the WHAS Steering Committee meetings and facilitated the work of the large group of investigators and field staff who made important contributions to this study.

The study has benefited greatly from the diverse group of collaborators from academia, the private sector, and government, including visiting scientists from abroad. Their expertise in geriatrics, epidemiology, physical disability, social psycho- logy, survey methodology, biochemical markers, and clinical pharmacology has enhanced both the design and conduct of the project. We believe that this report will be of benefit to a wide audience and will stimulate new analytic and research efforts.

Ultimately, the WHAS has the potential to play an important role in the development of effective treatments and preventive strategies for physical disability in all older persons. The WHAS, funded by the National Institute on Aging, is a prospective, observational study of 1, women age 65 years and older who were moderately to severely dis- abled, but not severely cognitively impaired, at study entry.

These women represent the approxi- mately one-third most disabled older women liv- ing in the community. This monograph presents comprehensive information on their physical dis- ability; health status, including disease and physiologic measures; health care and service utilization; and their daily lives. It also describes the representative population of women age 65 years and older from which the WHAS study population was drawn. These data were obtained from November to February during the baseline recruitment and evaluation of WHAS participants.

The goal of the WHAS is to determine the causes and course of physical disability. Using data from the baseline assessment, presented in this monograph, and from followup assessments performed every 6 months over 3 years, the study will: 1.

Examine the natural history of physical dis- ability; 2. Identify the major diseases and conditions re- sponsible for physical disability; 3. Evaluate causes of changes in physical func- tion over time, including both decline and im- provement; 4. Assess the role of health care utilization, community, and informal services in modify- ing the course and severity of disability; 6.

Identify subsets of disabled women at highest risk of progression of disability; and Determine opportunities for secondary and tertiary prevention of disability. This introduction provides a framework for the data presented in this monograph, including the significance of disability for older adults and for older women in particular, an overview of the de- sign and methods of the WHAS, and a description of the areas of unique data offered by this study.

Background and Rationale for the WHAS: The Import of Disability in Older Women The dramatic increases in life expectancy over the 20th century, the resulting increase in the older population, and the rising costs of long-term care have made age-associated disability and de- pendency matters of national concern.

Overall, 40 percent of people age 70 years and older report limitations in their ability to carry on their usual activities Cohen and Van Nostrand, Ac- cording to the U. Census, among persons age 65 years and older, 16 percent have difficulty with basic mobility-related activities such as walking short distances, and 12 percent have dif- ficulty with basic self-care tasks LaPlante, Five to 8 percent of noninstitutionalized adults age 65 years and older receive help with one or more activities of daily living ADLs Wiener et al.

In addition to this disability in com- munity-dwelling older adults, 7 percent of people age 65 years and older reside in a nursing home, The Women's Health and Aging Study including 8 percent of women and 5 percent of men Feinleib et al.

Ninety percent of these individuals are dependent in one or more ADLs Hing et al. Clearly, disability and depend- ency are highly prevalent in older adults. Disability in old age is associated with poor quality of life, dependence on formal and informal care providers, and often substantial medical and long-term care costs.

In addition, disabled persons are at increased risk of other adverse health out- comes, including further declines in function Branch et al, ; Manton, , acute ill- nesses and injuries Branch and Meyers, ; Fried and Bush, , falls Nevitt et al. The more severe the disability, the higher the risk of these outcomes. Successful prevention or delay of disability could make a substantial difference in health status and well- being, as well as in the care needs and care costs of the older population.

Recent research has added much to our understanding of the associations of specific diseases and comorbid- ity with physical disability. The major diseases reported to be associated with disability include heart disease, osteoarthritis, hip fracture, diabe- tes, intermittent claudication, stroke, chronic ob- structive pulmonary disease, visual impairment, hearing impairment, depression, and cognitive impairment.

Effective prevention requires an un- derstanding of the types of disability caused by specific diseases, the mechanisms underlying the etiology of disability, the relationship between disease severity and the development and pro- gression of disability, and the interactions of spe- cific comorbid diseases.

The WHAS seeks to define these aspects of dis- ability in older women for a number of reasons. Women make up the majority of the older popula- tion, represent a larger proportion of the total population at each higher age, report higher rates of physical disability, and spend more years in a disabled state.

They also make up a substantially larger proportion of the nursing home population and are more vulnerable in terms of need for for- mal and informal care because of their higher rate of widowhood, especially at the oldest ages.

The burden of disability in older women has wide- ranging and profound effects on older women themselves, their families, and the health care system. While it was recognized in designing this study that potentially valuable male-female com- parisons are sacrificed by examining women only. In , the Institute of Medicine of the Na- tional Academy of Sciences published the priori- ties for a national agenda for aging research Lonergan and Krevans, Its first priority in three of five areas included research "on the causes, prevention, management, and rehabilita- tion of disability," "on the most important social and psychological techniques to maintain and im- prove.

The data from this study will provide important information, with a breadth and level of detail generally not available, that will aid the policy and scientific communities in addressing these issues. This sampling frame represented all female Medicare beneficiar- ies as of September 1, The Health Care Financing Administration sent a letter to each woman de- scribing the study. Two weeks later the study Principal Investigator Linda P. Fried sent a sec- ond letter inviting their participation.

A study in- terviewer contacted women in their homes to ad- minister the screening questionnaire and deter- mine study eligibility.

Women residing in nursing homes at the time of contact and those no longer living in the catchment area were not eligible for screening. Some women who were listed on the Medicare files were found to be deceased. Of those sampled, 5, women were eligible for screening: 1, women could not be located or contacted, or refused screening, and 4, women were screened.

The screening interview was designed to iden- tify the approximately one-third most disabled older women living in the community. The ap- proach used was derived from previous research in which factor analyses indicated a clustering of difficulty in certain tasks, such that difficulty in one task was associated with difficulty in the other tasks in the group Fried et al.

It was found that physical disability can be usefully categorized into four domains consisting of related tasks primarily associated with: 1 mobility and exercise tolerance; 2 upper extremity function; 3 higher functioning tasks a subset of instru- mental activities of daily living, not including heavy housework ; and 4 basic self-care tasks a subset of non-mobility dependent ADLs.

Using this domain-oriented approach, evaluation of population-based data National Health In- terview Survey data from the Supplement on Ag- ing indicated that individuals who reported diffi- culty in two, three, or four domains represented one-third of persons residing in the community WHAS Manual of Operations, This concep- tual approach and empirical analysis provided the basis for defining study eligibility, based on self- report of difficulty in tasks in two or more do- mains of function see Appendix B for screening instrument.

Details of screening and eligibility criteria are discussed in Chapter 1. In brief, of the 4, women age 65 years and older who were screened, 3, were able to complete the interview on their own, 1, met study eligibility criteria, and 1, agreed to participate in the study. After signing an informed consent, study par- ticipants received an extensive interview in their homes. This interview ascertained many aspects of physical function and disability, including tasks affected, severity of difficulty or dependency, and adaptations to disabilities Fried et al.

Also assessed were history of physician diagnosis, symptoms and severity of over 20 diseases and conditions, current use of prescription and non- prescription medications, psychological function- ing, social support and social networks, health- related behaviors, and health care and service utilization.

The questionnaire for the baseline in- terview can be found in Appendix B. The inter- viewer also administered several performance- based measures of functioning functional reach, lock and key, buttoning a blouse, using a tele- phone, visual memory, and block construction , and measured height, weight, and visual acuity see Appendix C.

Two weeks later, by appointment, a trained nurse using a standardized protocol see Appendix D conducted a 4- to 5-hour examination of the study participant in her home.

The goal of the ex- amination was to validate the presence of specific diseases and physiologic states and to character- ize their severity. The examination included the following: blood pressure and heart rate; anthro- pometry; electrocardiogram and auscultation of the heart and lungs; 4-hour ambulatory electro- cardiogram; ankle:arm blood pressure ratio; as- sessment of musculoskeletal disease through ex- amination of the joints and hand photographs; screening audiometry; and pulmonary function assessed statically using spirometry and dynami- cally using measurement of oxygen desaturation at rest and with exercise.

Through supplemental funding from Corning Clinical Laboratories, the study also performed phlebotomy on participants who signed a separate informed consent; approximately 75 percent agreed to the procedure.

A trained phlebotomist visited the participant's home, by appointment, and phlebotomy was performed following a stan- dardized protocol. After initial processing, Corn- ing Clinical Laboratories analyzed fresh blood specimens for hematologic, biochemical, and hor- monal characteristics of participants.

Merck Re- search Laboratories provided support for the creation and maintenance of a blood repository. Detailed descriptions of the examination in- struments and procedures are provided in the relevant chapters of this monograph. A core element of this study was to character- ize the prevalence of the major chronic diseases in older adults, with comparably rigorous ascertain- ment for each disease. To accomplish this, algo- rithms were established for each of 16 diseases, utilizing state-of-the-art epidemiologic and clinical criteria for the presence of disease.

These algo- rithms and appropriate references are found in Appendix E. Disease presence was validated through self-report of physician diagnosis of dis- ease, reported symptoms, signs or physiologic measures obtained in the nurse's examination, and medication use. These data were supple- mented, as necessary, with confirmation of diag- nosis through questionnaires completed by the participant's primary care physician see Appen- dix F and with ongoing surveillance of medical records.

Finally, a small subset of WHAS participants were invited to participate in the Weekly Disabil- ity Substudy, a 6-month study aimed at character- izing short-term variability in function and testing the reliability of both self-report and performance indicators of functioning. The study was designed to select a sample of approximately women, with equal numbers of subjects in each of nine cells defined by age , and 85 years and older and level of disability two, three, or four domains of disability.

The women were vis- ited weekly over 6 months. Overall, women, evenly distributed in the nine cells, agreed to par- ticipate in this substudy; 6 dropped out after the first interview and 8 had fewer than 5 visits, ef- fectively creating a final substudy population of 99 women.

During weekly interviews, women were asked about physical function and incident acute and chronic diseases or injuries. Selected per- formance-based tests of function also were admin- istered. It is hoped that the comprehensive infor- mation on the presence and severity of disease, obtained using physiologic and clinical measures, and the rich data characterizing the dimensions of functioning, will make it possible to unravel the complexities of functional decline in older women.

In addition, the prospective component of the study 6-month followup interviews over 3 years will characterize change in function and relate it to underlying changes in disease status, taking into account the impact of medical care, psycho- social factors, and important life events. We expect this monograph to be of interest to a diverse group of people concerned with issues of aging, chronic disease, functional decline and dis- ability, and provision of long-term care services.

The chapters that follow present the baseline de- scriptive data from the WHAS on the functioning, diseases and other health, psychosocial, service utilization, and demographic characteristics of the one-third most disabled older women living in the community, as well as data from the population from which the study participants were drawn.

The WHAS provides unique data on the heteroge- neity of function even within the most disabled segment of the population, as well as on adapta- tions to disability employed by these disabled older women. The in-home nurse's examination also provides substantial depth in terms of de- scribing exercise tolerance and a range of physiol- ogic and disease characteristics.

Finally, these data offer important insight into the daily lives of the participants. Chapter 1 describes the characteristics of the entire screened population, the screening methods and eligibility criteria, and comparisons between those women who were and were not eligible for the WHAS. Chapters 2, 3 and 4 describe the heterogeneity of functioning in older, disabled women through both self-report and performance- based measures, and through the compensations adopted to maximize function.

Chapter 5 de- scribes the day-to-day living circumstances and characteristics of these community-dwelling, dis- abled women.

Chapter 6 provides data on health care utilization and coverage and receipt of pre- ventive services in this population of women, who are likely to be among the greatest consumers of care. Chapter 7 provides extensive information on the instrumental and emotional support re- ceived by these disabled women. Chapter 8 de- scribes psychosocial characteristics and perceived quality of life. Chapters 9 and 11 through 14 of- fer medical history, reported symptoms, and the results of physiologic measures obtained on home examination to characterize presence, manifesta- tions, and severity of cardiovascular, pulmonary, musculoskeletal, and neurologic diseases, and of visual and hearing impairment.

Chapter 10 de- scribes exercise tolerance using both graded exer- cise testing and self-report, as well as distribu- tions of body mass index and triceps skinfolds. Chapter 15 offers extensive data on medications used by these disabled older women with high rates of comorbidity.

Finally, Chapter 16 pro- vides insight into hematologic, biochemical, and thyroid function characteristics. Appendices pro- vide technical details of the sample design and disease ascertainment methodology Appendices A, E, and F.

The full instruments of the WHAS are also included to facilitate their use by the sci- entific community, including screening and base- line questionnaires Appendix B , and study pro- tocols for the interviewer's objective assessment of physical function Appendix C and the nurse's physical examination Appendix D. References Branch LG. Second Conference on the Epidemiology of Aging.. DHHS Pub. NIH A prospective study of functional status among community elders.

Am J Public Health Assessing physi- cal function in the elderly. Clin Geriatr Med Trends in the health of older Americans: United States, Vital Health Stat 3 Serum albumin level and physical disabil- ity as predictors of mortality in older persons.

JAMA Use of nursing and personal care homes by the civilian population, Agency for Health Care Policy and Research. PHS Morbidity as a focus of preventive health care in the elderly. Epidemiol Rev Preclinical disability: Hypothe- ses about the bottom of the iceberg. J Aging Health Risk factors for recurrent nonsyncopal falls: A prospective study. Health status and service needs of the oldest old: Current patterns and future trends. Milbank Mem Fund Q. Physical disability in older adults: A physiological approach.

J Clin Epidemiol The na- tional nursing home survey: summary for the United States. Vital Health Stat 13 Prevalence and outcome of low ADL and inconti- nence among the elderly: Five years follow-up in a Japanese urban community. Arch Gerontol Geri- atr LaPlante MP. Prevalence of mobility and self-care disability— United States, MMWR A national agenda for research on aging.

New Engl J Med Fall risk index for elderly patients based on num- ber of chronic disabilities. Am J Med Risk factors for falls among elderly persons living in the community. N Engl J Med Warren Ml. Knight R. Mortality in rela- tion to the functional capacities of people with disabilities living at home.

J Epidemiol Comm Health Measuring the activities of daily living: Comparisons across national surveys. Linda P. Fried, E. Manton KG. A longitudinal study of func- tional change and mortality in the United States. Kasper As described in the Introduction, an age- stratified sample of women age 65 years and older residing in the community in Baltimore, Maryland was evaluated for eligibility for the Women's Health and Aging Study WHAS.

The objective of the screening was to identify and re- cruit the one-third most disabled women living in the community. A 20 to 30 minute home interview using com- puter assisted personal interviewing techniques was administered to women who agreed to par- ticipate in the screening assessment. This screener questionnaire included batteries assess- ing disability status and cognitive functioning, both of which were used to determine study eli- gibility. Information was also obtained from par- ticipants on demographic characteristics, self- reported health status, and history of physician- diagnosed chronic conditions see Appendix B for the complete screening interview.

All screening interviews were completed per- sonally by respondents. Women who were too cognitively impaired to respond to the screener questions or who were otherwise unable to com- plete the screening interview themselves were excluded.

Participants completing the screening interview were considered eligible for the WHAS if they reported difficulty in one or more items in two, three, or four domains of disability see In- troduction to this monograph and had a Mini- Mental State Examination MMSE score Folstein et al, of 18 or higher. A total of 4, women agreed to be screened, of whom could not personally complete the screening in- terview.

Thus, the screening interview was ad- ministered to 3, women. Disability Patterns in the Screened Population Four domains of disability were considered in the screening process: upper extremity, mobility, higher functioning tasks required for independ- ent living in the community, and self-care. The top half of Table 1. For each task, the participant was asked whether, by herself and without help from another person or special equipment, she had any difficulty.

Data are also presented on the percentage of women with diffi- culty in one or more items in a domain. The highest rate of difficulty was in the mobil- ity domain, with over 49 percent of screened women reporting difficulty in one or more items. About 22 percent of women reported difficulty in the self-care domain. Rates of difficulty for all individual self-care items were slightly higher than national estimates for women age 65 years and older Dawson et al.

For example, 8. Consistent with previous work in this field, the prevalence of difficulty in each domain and for specific items increases dramatically with increasing age Table 1. The bottom half of Table 1. Women who had difficulty in no domains or only one domain were ineligible for the study and constituted The percent of women with difficulty in no domains dropped steeply with increasing age, from more than 50 percent in those age 65 to 74 years to slightly more than 22 percent of those age 85 years and older.

Most of the women with two domains of difficulty had mobility and upper extremity problems, while the majority of women with dif- ficulty in three domains reported problems with these two domains as well as problems with ei- ther higher functioning or self-care.

The most se- verely disabled women — those with difficulty in all four domains — constituted about 13 percent of the screened population, but this percentage rose steeply with increasing age, to 30 percent of those age 85 years and older. The domain approach used in the WHAS to select a moderately to severely disabled study population identified a cohort with diverse pat- terns and levels of disability. Many combinations of disabilities are represented in the eligible study population.

The domain approach to screening was successful in including women with less common patterns of disability who are typically classified as nondisabled using more conventional approaches to disability assess- ment, such as screening for mobility or self-care disability alone. For example, a small proportion of women with two domains of disability had problems with upper extremity function and ei- ther higher functioning or self-care tasks.

This important subgroup of women would have been excluded if mobility difficulty, which was ex- tremely common in those eligible for the study, were a fixed requirement for study eligibility. Table 1. For example, a small number of screened women 0. Closer examination revealed that these women generally reported only a little or some difficulty in bathing or dressing and had no difficulty in tasks such as walking a quarter of a mile, doing heavy housework, and lifting and carrying 10 pounds.

Their disability was thus likely to be mild and it was appropriate for them to be ex- cluded from the study. Demographic and Health Characteristics Table 1. A slightly lower percent- age of the population was age 65 to 74 years than the U. Bu- reau of the Census, While Black women made up 8 percent of the U. The screened population had a broad range of educa- tional attainment: a third had less than 9 years of education and nearly a fifth had more than 12 years.

Overall, 42 percent of the screened popu- lation in the WHAS had 12 or more years of edu- cation compared to 56 percent for women age 65 years and older in the United States Aging America, For each category listed in Table 1. For the total population, Eligibility ranged from 28 percent for women age 65 to 74 years to 51 percent for women 85 years and older.

Higher eligibility rates were seen for Afri- can American women, women with less educa- tion, and those with lower income. Married women were younger and had lower eligibility. Less than 12 percent of women reporting excel- lent health were found eligible for the study.

In contrast, 80 percent of women reporting poor health were eligible, and an additional 7 percent of these women were cognitively impaired. The mean MMSE score was slightly higher for the non-disabled ineligible than for those who were eligible.

Women classified as cognitively im- paired who were administered the test had an MMSE range of to 17 and a mean score of For all conditions listed there is a substantially higher prevalence in women eligible for the study than in the non-disabled ineligible. The absolute difference in prevalence rates is greater for rela- tively common diseases such as myocardial in- farction, angina, diabetes, arthritis, and hearing problems.

In contrast, the ratio of prevalence rates in the eligible versus non-disabled ineligi- ble is greater for rarer conditions such as con- gestive heart failure, stroke, and Parkinson's disease. Women excluded from the study because they scored 17 or less on the MMSE had preva- lence rates that were similar to the ineligible non-disabled group for most conditions.

For stroke, hip fracture, and hearing problems, con- ditions that have previously been demonstrated to be associated with cognitive impairment, the prevalence was substantially higher in the cog- nitively impaired group than in the ineligible non-disabled group. It also presents this in- formation according to whether women partici- pated in the full baseline evaluation or declined to participate further. Of the 1, eligible screener respondents, 1, Study participation was defined as completing both the baseline in- terview and the nurse's examination about 2 weeks later.

Overall, women who participated in the study were very similar to the total eligible population on the characteristics shown in Table 1. However, in comparing the eligible participants to nonparticipants second and third sets of columns , certain differences were seen. Among participants, a larger propor- tion were age 65 to 74 years and a smaller pro- portion were age 85 years and older. Blacks par- ticipated at a higher rate than Whites, with 28 percent of participants and 20 percent of non- participants being Black.

The participant group included a somewhat higher proportion with more than 12 years of school, with only slightly lower proportions in the other education sub- groups. A substantially higher proportion of nonparticipants did not know or refused to re- port their income.

Marital status was quite similar in those who did and did not participate, and there was little difference in the distribution of self-reported health status among those who did and did not participate in the full study. Mean MMSE score was similar for both groups. In summary, there were no major disparities be- tween eligible women who agreed to participate in the full study and those who declined.

The 12 The Women's Health and Aging Study group who entered the study was somewhat younger, more often African American, and more often had greater than a high school education than the group that declined, but the two groups had similar marital status, self-reported health, and cognitive function. Classification of Disability Categories in This Monograph As stated above, a screening procedure that assesses multiple domains of function was valu- able in selecting a heterogeneous group of mod- erately to severely disabled women for this study.

For the purpose of presenting descriptive data in this monograph, however, a more con- ventional approach to disability classification is used. Data are presented for study-eligible par- ticipants according to three levels of disability: receipt of help from a person to perform one or more basic activities of daily living ADLs bathing, dressing, eating, using the toilet, get- ting in or out of bed or chairs , no receipt of help but difficulty with one or more ADLs, and mod- erate disability.

The last group includes those who meet the criteria for the study but have no difficulty with ADLs. This classification system focuses on ADLs because they are the most commonly assessed measure of disability in old age.

Clinicians and other care providers, researchers, and policy makers all have experience with these categories of disability and understand the functional problems and general characteristics of older people who have these disabilities.

The category termed moderate disability includes those women disabled enough to qualify for the study but not so disabled as to have difficulty with ba- sic self-care activities.

It therefore includes women with difficulty in two or three of the do- mains assessed in the screening interview. These data are particularly useful for understanding functional characteristics of eligible women with moderate disability and comparing them with women who were ineligible for the study.

Overall, nearly all women classi- fied as moderately disabled had upper extremity problems, virtually all reported difficulty with one or more items in the mobility domain, and almost half had difficulty in the higher function- ing domain.

Comparing eligible women with moderate disability with women who reported some disability but were ineligible for the study, more than 83 percent of those with moderate disability had difficulty in tin- upper extremity domain as compared with 22 percent of ineligible women with one domain of disability.

More than 99 percent of the moderately disabled women had difficulty in the mobility domain compared with 71 percent of women with difficulty in one domain.

Furthermore, more than 60 percent of women with moderate disability had two or more areas of difficulty in mobility, compared with less than one-quarter of women with difficulty in one domain. Finally, there was almosl no difficulty m the higher functioning domain in the women with one domain of difficulty, while more than 10 percent of moderately disabled women had problems with this domain. These data clearly demonstrate that women with moderate disability were not as disabled as those with difficulty in ADLs.

The question still remains, however, as to whether there were women with one domain of functional difficulty whom some observers might classify as more disabled than certain study-eligible women with two domains of difficulty. The goal of screening was to have no woman classified as eligible for the study who was less disabled than a noneli- gible woman, and no woman classified as ineli- gible who was more disabled than an eligible woman.

However, there is no gold standard by which to measure this. When assessing multiple domains of dis- ability it is sometimes quite subjective as to what combination of disabilities is more severe, and, in fact, which specific health state or pattern of dis- ability individuals would find less desirable may be a matter of personal choice. Format of Monograph Tables This chapter describes the population who were screened to obtain a sample of the one-third most disabled women living in the community, the study population for the WHAS.

Beginning with Chapter 2, all data presented are limited to the 1, women who make up the WHAS study population. Most tables present descriptive in- formation for the total study population and within the three age strata and the three disabil- ity groups described above. In general, the tables show the actual number of women evaluated, but all other data are weighted to give estimates for the target population the women in the study represent.

Appendix A describes the sampling strategy and gives general variance estimates that may be used to estimate the precision of the population rates and means shown in all tables. For a small number of variables, there was a large age gradient in rates; in these cases the in- formation according to disability status is pre- sented both as unadjusted and age-adjusted rates. For most variables, age adjustment made little difference compared to the unadjusted rates for the disability categories, and only unad- justed rates according to disability status are presented.

References Aging America. Trends and Projections. FCoA Washington, DC: U. Department of Health and Human Services. Aging in the eighties: Functional limitations of individuals age 65 years and over.

Advance Data No. J Psychiatr Res Bureau of the Census. Sixty-Five Plus in America. Government Printing Office. Results are based on non-missing data.

Excellent 9. For these variables results are based on non-missing data. Percents and means are based on weighted data. Excludes women who were not administered the screener due to extreme cognitive impairment. What is the highest grade in school or year of college that you completed?

Social Security, retire- ment income, job earnings, public assistance, help from relatives, rent from property, and any other income should be included. If the subject did not know or refused to respond, she was shown a card with income ranges and asked to pick a range. Are you now married, or are you widowed, separated, divorced, or have you never been married? Excellent 59 4. Table uses unweighted data. Excludes cognitively impaired women. No ADL difficulty; disabled in two or more domains see Chapter 1.

The screener question is in the form "By yourself, that is, without help from another person or special equipment, do you have any difficulty. The question is in the form "Because of a health or physical problem, do you have any difficulty.

This chapter presents the basic demographic character- istics of this population and further characterizes their functional status and disability, including physical and cognitive functioning. The items on physical functioning were drawn from a number of sources. Questions on mobility walking specific distances, walking up or down stairs and ability to perform heavy housework are adapted from the Rosow and Breslau scale The question on lifting or carrying 10 pounds is from the physical function scale devel- oped by Nagi For each of 20 tasks, the per- cent of the study population reporting any diffi- culty as well as the level of difficulty reported is presented.

Even though all women in the study are disabled, there is great diversity in the type and amount of functional limitation. Table 2. These weighted data indicate that 15 percent of the disabled population in the geographic target area for this study was age 85 years and older.

For other demographic data presented in Table 2. Twenty-eight percent of women were Black and 71 percent were White. Racial composition, however, varied by age group, with the proportion of African American women decreasing with increasing age. There was a wide spectrum of both educational attainment and household income levels among these disabled women. For example, at the two extremes, almost 41 percent had less than a ninth-grade education and 18 percent had more than a high school edu- cation.

The oldest women and those receiv- ing help with ADLs were more likely than others not to provide income information. A high proportion of women in the study were widowed, particularly among the oldest group. At the time of the study only 25 percent were mar- ried, and this number decreased dramatically 20 The Women's Health and Aging Study with age, from 34 percent of those age 65 to 74 years to 6 percent of those age 85 years and older Table 2. Severity of disability and age were strongly as- sociated.

The oldest old had the highest proportion with any ADL difficulty and the highest propor- tion who received help with ADLs. Seventy-five percent of the oldest women reported any ADL difficulty, and 22 percent received help, while only 25 percent of women age 85 years and older had moderate disability. In contrast, among those age 65 to 74 years, 61 percent had any ADL difficul- ties and 15 percent received help, while 39 percent of this age group had moderate disability Table 2.

Study participants also showed diversity in terms of the combinations of disability present. For example, Figure 2. Figure 2. More than 40 percent of women age 65 to 74 years reported difficulty in only two domains, while nearly 50 percent of those age 85 years and older were disabled in four do- mains. Not surprisingly, high proportions of women reported difficulty with mobility and tasks demanding exercise tolerance Table 2.

For ex- ample, 83 percent reported difficulty stooping, crouching, or kneeling, and 74 percent reported difficulty walking for a quarter of a mile. Sub- stantial proportions, 38 and 26 percent, respec- tively, were completely unable to do these activi- ties. More than half of the women reported diffi- culty climbing up 10 steps without resting and one-fourth reported difficulty walking across a small room.

Across several mobility-related tasks, the prevalence of women reporting difficulty tended to increase modestly with increasing age, while in- ability to perform the task tended to increase more dramatically. However, there was greater variation by age on some tasks, such as walking across a small room, than on others. Overall, variation in difficulty with specific tasks appeared to be greater by disability level than by age.

For example, of those who reported receiving help with ADLs, 60 percent had difficulty walking across a small room, and 27 percent were unable to do this very basic task.

For those with moderate disability, 7 percent reported difficulty and 0. Ninety percent of the women with mobility problems had difficulty in two or more tasks in this domain Figure 2. In contrast, a high pro- portion of those with difficulty in upper extremity tasks, IADLs, or self-care had difficulty in only one task out of the four to six assessed.

Less than 15 percent of the study population had difficulty in more than two self-care tasks. Although these women reside in the commu- nity, they had a high frequency of difficulty with many critical aspects of functioning. About 66 percent of the study population reported diffi- culty lifting or carrying a pound bag of grocer- ies and almost 12 percent had difficulty turning a key in a lock.

There were few differences by age. Variations in reporting difficulty did occur by dis- ability level, however. Over 40 percent said they were unable to lift 10 pounds and 20 percent said they could not turn a key in a lock.

These tasks are viewed as important components of routine daily life Lawton and Brody, Age appears to be an important correlate of difficulty for many of these tasks and activities.

Sixty-five percent of women age 85 years and older had difficulty shopping for personal items, and half were unable to shop for themselves. One-fourth of the oldest women had difficulty preparing their own meals, and 18 percent could not do this.

Overall, of those who reported difficulty, a higher percentage were unable to perform these IADL tasks than was the case for tasks in other areas of functioning. For example, 41 percent of the total population re- ported difficulty shopping; two-thirds of these were unable to shop for themselves. Similarly, half of those with difficulty managing money re- ported being unable to do it, and over half of those with difficulty preparing meals said they could not prepare them.

Finally, Table 2. Inability to do ADLs was relatively rare under 5 percent , with the exception of bathing or showering 12 percent. A slight to moderate age-gradient in prevalence of difficulty was apparent. The association with se- verity of disability was much more pronounced, however. For example, prevalence of difficulty with bathing or showering rose from 62 percent for those with ADL difficulty but receiving no help to 91 percent of those receiving help with ADLs. Prevalence of difficulty dressing, using the toilet, and eating was twofold higher in those receiving help with ADLs compared with those who had difficulty but received no help.

Summary The data in Tables 2. Figures 2. This includes difficulty with func- tioning in multiple domains, as well as in varying numbers of tasks within a domain. As demon- strated in Chapter 1, the population of dis- abled women clearly reported poorer functioning than an age-comparable cross section of elderly women.

Yet even among this population of moder- ately to severely disabled women, there is a broad spectrum of difficulty and dependency in a wide variety of tasks.

Studies of illness in the aged. The index of ADL: A standardized measure of biological and psychosocial function. Assessment of older people: Self-maintaining and instrumental activities of daily living.

Gerontologist An epidemiology of disability Rosow I, Breslau N. A Guttman health among adults in the United States. Milbank Mem scale for the aged. J Gerontol Fund Q Descriptive statistics are based on weighted data. Social Security, retirement income, job earnings, public assistance, help from relatives, rent from property, and any other income should be included.

The question is in the form "By yourself, that is, without help from another person or special equipment, do you have any difficulty. The percents of participants reporting their levels of difficulty may not add up to the percent reporting difficulty due to 1 rounding 2 level of difficulty not reported.

The screener question is in the form "Because of a health or physical problem, do you have any difficulty. The screener question is in the form "Because of a health or physical problem, do you have any difficulty The presence of the condition was confirmed in the baseline interview. How much difficulty do you have? The question is in the form "Do you have any difficulty Adaptation to Disability Jeff D. Fried In studies of older adults, physical function and disability are usually assessed in terms of self-reported difficulty or inability to perform specific tasks of daily life across a range of func- tions, e.

An individual's assessment of the dif- ficulty doing a task may be affected both by self-perception and by adaptations made to com- pensate for, or minimize, a decline in function. For example, an individual who has installed rails and a chair in the bath because of concerns about unsteadiness may, when questioned, re- port no difficulty when bathing. Therefore, in studies aimed at assessing disability in the eld- erly, information on adaptation to disability can provide important insights into a broader spec- trum of functioning than asking about difficulty alone Fried et al.

This chapter presents data from the Women's Health and Aging Study WHAS describing a spectrum of functioning among moderately to se- verely disabled women and the adaptations they make, including changes in the manner in and frequency with which they perform certain tasks, functional limitations related to structural as- pects of the housing environment, and use of walking aids. These data provide insight into the daily lives of these women and the approaches used to compensate for disability Percepfion of Difficulty and Adaptation to Difficulty For selected tasks, Table 3.

For a subset of these tasks, the proportion receiving help is also shown. Table 3. For example, although 48 percent of participants in- dicated no difficulty in walking up 10 steps with- out resting, 37 percent of these women per- formed this task less often than before. Simi- larly, 51 percent of participants who indicated that they had no difficulty walking one-quarter of a mile, walked this distance less often. In con- trast, 92 percent of women who reported diffi- culty walking this distance walked it less often.

Participants were also asked whether they per- formed selected tasks differently. Changes in method were reported at even higher rates by women reporting difficulty with these same tasks, 68 percent and 86 per- cent, respectively.

The data in Table 3. Such adaptation is likely a re- sponse to functional decrements made in an ef- fort to preserve task performance.

Identifying these adaptations may be useful in understand- ing how individuals minimize disability and maintain independence. It is notable that tasks for which women were most likely to make adap- tations were those for which this population had the highest prevalence of task difficulty or inabil- ity to perform. For example, the greatest amount of modification was reported for tasks associated with the highest mobility and exercise-tolerance requirements and the highest rates of reported difficulty and inability.

These tasks included heavy housework and climbing stairs. The importance of these modifications in task performance remains to be determined. However, these results suggest additional dimensions for describing function beyond the existing concep- tual frameworks used to identify the presence of disability Institute of Medicine, ; Nagi, ; World Health Organization, These data also suggest that the prevalence of func- tional decrements may be greater than that as- certained by assessing only difficulty or inability to perform activities.

Eighty percent of these disabled women resided in homes where at least one step up or down was necessary to en- ter their home. With increasing age, a smaller proportion of women resided in homes with an entry step s.

Among all women whose homes had an entry step s , almost 11 percent reported they were unable to walk up 10 steps without the assistance of another person or special equip- ment. The proportion unable to climb 10 steps increased with increasing age and disability level. For women who had entry steps, 19 per- cent of those age 85 years and older and 34 per- cent of those receiving help with ADLs reported being unable to climb 10 steps without assis- tance.

Of the 56 percent of women in this population who lived in homes that did not have a bath- room, bedroom, and kitchen located on the same floor, nearly one-third reported needing them on the same floor. With increasing age and disabil- ity level, the proportion of women needing their bathroom, bedroom, and kitchen on the same level increased. Among those age 85 years and older who did not have a residence with a bath- room, bedroom, and kitchen on the same floor, 42 percent needed this arrangement, in contrast to 28 percent of women age 65 to 74 years.

In women with ADL difficulty who received help, 57 percent did not have their bathroom, bedroom, and kitchen on the same floor, and 58 percent of these women, compared with 17 percent of the moderately disabled, needed them on the same floor. Few women had a walk-in shower. The pro- portion that needed a walk-in shower was about 20 percent and did not vary with age, but was 30 The Women's Health and Aging Study strongly related to severity of disability. Among women with ADL difficulty who received help, 45 percent who did not have a walk-in shower stated that they needed one because of a health or physical problem.

Overall, 12 percent of participants had stopped using one or more rooms in their homes because of a health or physical condition. The rates were highest in the oldest women and the most disabled. Fifteen percent of women age 85 years and older and 35 percent of women receiv- ing help with ADLs reported that they had stopped using one or more rooms in their home. On average, women who reported reduction in use of living space due to their health no longer used 30 to 40 percent of the rooms in their homes.

Use of Walking Aids Table 3. When walking, 37 percent of the population used a cane, 32 percent held onto another person, and 11 percent used a walker. Overall, 3 percent of participants could not walk and 11 percent sometimes used a wheelchair. The proportion of participants using each walking aide increased with both age and level of disability, independent of the environ- ment.

In addition, 41 percent of this population reported that they reached out for, or held onto, furniture or walls to assist them in walking. This is another example of a compensatory strategy. Another adaptation, reported by 50 percent of these disabled women, is the use of shopping carts for support while shopping.

These data in- dicate that such adaptations, or compensatory strategies, are frequently used to facilitate ongo- ing performance of tasks such as walking in the home or shopping for personal items. They also suggest that the proportion of this disabled population that reported use of assistive devices may not include the full spectrum of individuals who need them or may have difficulty with pos- tural stability. The environment in which walking occurred influenced participants' choices of assistive de- vices or other strategies to compensate for their disabilities.

Overall, canes, wheelchairs, and the assistance of another person were used less often when the respondents walked inside the home than outside. For example, 19 percent used a cane when ambulating inside while 34 percent used one when walking outside the house. Simi- larly, 5 and 9 percent, respectively, used a wheelchair, and 6 and 29 percent, respectively, used the assistance of another person when walking inside, compared with outside, the home.

This difference likely results from the lesser demands of walking inside in a familiar environment. Summary Characterizing adaptations to disability ex- pands our insight into the spectrum of function- ing among disabled older women beyond what can be learned through the usual assessment of difficulty and need for help.

Further delineation of the types of adaptation used by older people and the predictive importance of such compen- sations will define whether this dimension can lead to better understanding of risk for further functional decline and of opportunities for pre- vention of disability References Fried LP, Herdman SJ, Kuhn KE.

Rubin G, Turano K. Preclinical disability: Hy- potheses about the bottom of the iceberg. Institute of Medicine. Committee on a National Agenda for Prevention of Disabilities. Disability in America. Toward a National Agenda for Prevention. Nagi SZ. An epidemiology of disability among adults in the United States.

Milbank Mem Fund Q Rosow I, Breslau N. A Guttman health scale for the aged. World Health Organization. Geneva: World Health Organization. Does less often 5 For these variables, results are based on non-missing data. The screener question is in the form "By yourself, that is without help from another person or special equipment, do you have any difficulty. The question is in the form "Do you [do the task] less often than you used to?

Do you usually receive help from another person [doing the task]? Continued Continued 33 The question is in the form "By yourself, that is without help from another person or special equipment, do you have any difficulty.

Have you cut back on the number of meals you prepare because your health makes it difficult? Have you changed the types of food you prepare or given up preparing certain foods because your health makes it difficult? Are you less involved in managing your money than you used to be because your health or physical condition makes it difficult? Does another person usually help you with managing your money? Yes No By yourself, that is without help from another person or special equipment, do you have any difficulty walking up 10 steps without resting?

Use a cane The furniture or walls Fried In performance-based tests, which objectively as- sess various aspects of physical functioning, an individual typically performs a task in a stan- dardized manner and performance is measured with predetermined, objective criteria, often in- cluding time to completion or counting of repeti- tions.

In recent years, these measures have been increasingly employed in studies of functional status and disability in old age. In older persons, performance measures provide information that complements what can be learned from a clini- cian's physical examination Tinetti and Ginter, and from traditional, questionnaire-based approaches that assess disability through proxy or self-report Guralnik et al.

The Women's Health and Aging Study WHAS included physical performance meas- ures because they offer objective and detailed in- formation about functional capacity and there- fore provide valuable information for under- standing the causal pathway from diseases to disability.

The specific performance tests se- lected assess a spectrum of functioning, from basic abilities such as balance to complex activi- ties such as putting on a blouse. These measures also quantify physical function along a continu- ous scale, ranging from very poor to excellent. They are therefore expected to be particularly valuable in detecting change in function over time.

A variety of performance tests have been de- veloped for use in institutions Gerety et al. In general, these tests may be categorized by either the domain of functioning they assess e.

The first part of this chapter groups the re- sults of performance-based tests assessing basic physical abilities according to lower extremity and upper extremity function. Performance of more complex tasks that mimic activities in daily life are reported later in the chapter. Compression stockings offer varying levels of compression, which is measured in millimeters of mercury mmHg. The higher the number, the more compression you get. Generally, no. Most people use the term interchangeably, including the manufacturers.

Compression stockings are typically put on in the morning they are easier to get on before swelling begins and taken off before going to bed. A prescription from your physician or midwife is required by your insurance company to support that these stockings are medically necessary. Benefits of wearing maternity compression stockings during pregnancy and after delivery: Reduces swelling and discomfort in your feet, ankles and legs - especially after being on your feet for an extended period of time.

Maternity Compression Stockings though Insurance 1 Natural Way works with many insurance providers to offer maternity compression stockings to expecting and postpartum moms.

Graduated compression design maximizes comfort - delivers greater pressure in the feet and ankles and progressively decreases toward the top of the stockings. Fitted design keeps the stocking from falling down or bunching up in your shoe.

Not to mention swollen ankles and legs?

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See the seller's listing for full details. See all condition definitions opens in a new window or tab. Massage Functions:. Air Compression. Custom Bundle:. Item Length:. It also comes in handy for individuals who may have trouble reaching the controls. The harder the controls are to reach, the less you'll be adjusting them, which means you might not receive an optimum massage. Having all the controls in a convenient, easy-to-reach spot is ideal.

These are general , multi-purpose massagers that could be used on any part of the body. Some are manually operated; others are electric and produce some type of vibrating action.

These massagers work via compression. Some wrap around the calf alone; others encompass the feet and possibly the thighs. These calf massagers are sturdy and powerful with the greatest variety of massaging options. There are many reasons why you may be experiencing pain in your calves. Some may be the result of your lifestyle while others may be the result of an underlying medical condition.

Here are just a few of the reasons why you may have sore calf muscles. Deep tissue massage targets particularly painful spots inside your body. It isn't as rhythmic as many other massage techniques because it uses pressure to reach muscles and tendons located deep beneath the skin. It is useful for relieving tension and helping with muscle injuries. Shiatsu means "finger pressure. It is performed without the use of oils and can even be done through light clothing.

This technique is used to treat a wide variety of conditions, from stress and tension to headaches and back pain. Different movements and techniques are better suited for different types of pain. Some techniques utilize smooth, relaxing strokes while others can actually be quite painful. Some massages are effective in as little as 15 minutes; others require an hour of work. If you just want to relax and knead away the tension, that's a much different type of massage than one an athlete would receive after a grueling event.

Best Calf Massagers. BestReviews spends thousands of hours researching, analyzing, and testing products to recommend the best picks for most consumers. We only make money if you purchase a product through our links, and all opinions about the products are our own.

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There are roughly 80 massage options available, ranging from the popular Swedish massage to the Hawaiian Lomi Lomi massage, which unblocks trapped energy.