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The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 57:M716-M721 (2002)
© 2002 The Gerontological Society of America

Chronic Disease, Functional Status, and Self-Ascribed Causes of Disabilities Among Noninstitutionalized Older People in Spain

Emiliana Valderrama-Gamaa, Javier Damiána, Ana Ruigómezb and José M. Martín-Morenoa,c

a Institute of Health "Carlos III, " Madrid, Spain
b CEIFE (Spanish Centre for Pharmacoepidemiologic Research), Madrid, Spain
c Department of Preventive Medicine and Public Health, Autonomous University of Madrid, Spain

Javier Damián, Centro Nacional de Epidemiología, Instituto de Salud Carlos III, C/ Sinesio Delgado 8, 28029 Madrid, Spain E-mail: jdamian{at}isciii.es.


   Abstract
Top
 Abstract
Methods
 Results
 Discussion
 References
 
Background. A major component of disability is related to chronic disease, but the study of self-reported causes of disability could add new aspects in understanding this process. The main objective of this work was to determine the associations between chronic diseases and disability and to describe the pattern of self-reported causes of the disabilities present in older persons.

Methods. We carried out a survey in a probabilistic sample of people aged 65 and older of the city of Madrid. The initial sample size was 1001. Subjects were interviewed in their homes. We asked about the presence of 14 chronic conditions. Self-reported difficulty and dependence in 9 noninstrumental activities of daily living (ADLs) were ascertained. Subjects were asked to report the main cause responsible for the disability. Multivariate logistic regression models were constructed to estimate the association of each chronic condition with the probability of having disability.

Results. Final sample size was 772 people (overall response rate 77.0%). Interviews answered by proxies were 7.5%. Only 4.5% declared no chronic condition. Osteoarthitis/rheumatism was the most prevalent condition (56.8%). In addition, 63.2% were independent, 21.3% were independent with difficulty (in at least one ADL), and 15.5% were dependent (in at least one ADL). Subjects attributed to osteoarthitis and to aging 41.8% and 17.1% of all disabilities, respectively. Chronic conditions strongly associated with disability were cerebrovascular disease (adjusted odds ratio [OR]: 3.51 [95% confidence interval: 1.44–8.60]), depression/anxiety disorders (OR: 2.72 [1.83–4.05]), and diabetes (OR: 2.18 [1.24–3.83]).

Conclusions. Cerebrovascular diseases, depression/anxiety disorders, and diabetes were the conditions more clearly related to disability. On the other hand, a large proportion of subjects attribute their disabilities to osteoarthritis and old age.

PATTERNS of disease change with aging. While acute disease represents the main cause of health problems in young people, chronic conditions and their impact on functional performance are the most prevalent health problems in older persons. Functional impairment and its negative impact on quality of life and well being are strong predictors of mortality and institutionalization in this population (1).

Functional assessment in older people may be considered at two levels: assessment of the individual as part of clinical care and assessment of populations. Different authors (2)(3) have highlighted the potential benefits of functional assessment for individuals in clinical care. On the other hand, assessment of populations should both enable appropriate planning for health needs and correct resource allocation to prevent disability.

Much of the work on physical functioning and disability has been accomplished with no consideration to the specific disorder causing the disability (1). However, a comprehensive understanding of disability requires linking functional disability to the underlying diseases implicated. Moreover, one preventive approach to reduce the prevalence of functional decline is to reduce the prevalence of the chronic medical conditions that lead to functional impairment (4). The link between diseases and disability can be studied from two perspectives: investigating statistical associations between diseases and disabilities and exploring the ascribed causes of disability. In spite of the interest in the latter approach, studies on self-reported causes of disability are scarce (5)(6)(7).

The purpose of this study is to determine the prevalence of chronic diseases, disabilities, and their causes in a representative sample of the noninstitutionalized population of elderly adults in Madrid, Spain. We linked chronic diseases and disability by examining the statistical associations and by asking the study subjects the cause of their disabilities.


   Methods
Top
 Abstract
 Methods
Results
 Discussion
 References
 
A cross-sectional study was carried out from May 1994 to March 1995 in the city of Madrid, Spain. The sampling frame comprised all noninstitutionalized older people (aged 65 and older) who were registered on the last Municipal Roll (1991). Sampling was carried out with proportional stratification by gender and municipal district. To ensure that the sample included a sufficient number of persons from the oldest age groups, nonproportional age stratification was performed with three equal-sized strata (65–74, 75–84, and >=85). A sample of 1001 subjects was obtained through this method.

A structured questionnaire was used to collect self-reported health information on chronic diseases, disabilities, and their causes, sociodemographic data, self-rated health, and other variables. Subjects were interviewed in their homes.

Chronic Disease
Individuals were asked about the presence of 14 chronic conditions using the following question: "Has your doctor ever told you that you suffer from ... (disease)?"

Functional Disabilities
Self-reported difficulty and dependence in performing nine noninstrumental activities of daily living (ADLs) was ascertained. Additional items to the original ADL scale included ability to exit the household, specifically moving around within/outside the household, as a broader concept than walking (8). For each activity, subjects were asked if they had difficulty because of health problems. If the answer was affirmative, respondents were asked if they actually received help from another person and about the leading cause of that disability. No attempt was made to investigate the ability to carry out various activities that were not performed (e.g., if a person never tried to go outside, no attempt was made to find out whether he or she had difficulties performing this activity in the event it was required). Individuals were divided into three groups: (i) Independent without difficulty, if they required no personal assistance and reported no difficulty in any ADL; (ii) Independent with difficulty, if they required no personal assistance but reported some degree of difficulty in one or more ADL; and (iii) Dependent, if they usually received personal assistance in one or more ADL. The last two groups comprised the disability group. Use of assistive devices was considered no personal assistance.

Self-Reported Causes of Disability
Subjects were invited to report the condition or disease responsible for the disability. Then, conditions and diseases were later coded by two research assistants blinded to the objectives of the study, by assigning the most specific International Classification of Disease (ICD-9) code possible for each condition. In addition, codes were grouped within attending system-related diseases: arthritis and related diseases (ICD-9 codes 713 to 737, 905, and P815); vision impairment (365 to 369, 870); dementia (290); cerebrovascular disease (342, 434 to 440); hip or lower-body bone fracture (808 to 828); depression and anxiety disorders (308, 311); hearing impairment (381 to 389); heart disease (410 to 429); lung disease (491 to 518); peripheral vascular conditions (443 to 454, 459); gingival and periodontal disease (523 to 528); gastrointestinal disease (529 to 537, 569 to 575); general and ill-defined symptoms (780 to 799); and motor problems of extremities (V492).

Statistical Procedures
All analyses were weighted to take into account the sampling design. Logistic regression models were used to test associations between each chronic condition and disability. All p values are two-sided.


   Results
Top
 Abstract
 Methods
 Results
Discussion
 References
 
From the initial sample of 1001 subjects, 196 refused to participate, and 33 could not be located or failed to provide reliable information. The population included in the final analyses comprised 772 individuals (overall response rate: 77.1%; voluntary response rate: 79.8%). Percentage of surveys completed by proxies was 7.5%. Table 1 shows the sociodemographic characteristics of the sample. The percentage of women was 60.4%. Mean age (standard deviation) was 74.4 (7.1). Fifteen percent of the participants lived alone. Regarding health status, 7% rated their health as very good, 41.8% as good, 36.7% as fair, 10.3% as poor, and 3.6% as very poor.


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  		Table 1. Sociodemographic Characteristics of Study Subjects

 
Table 2 presents the prevalence of chronic conditions; only 4.7% of the studied individuals declared they were free of any of the studied chronic conditions, and 80.1% suffered from two or more conditions. The most prevalent disorders were osteoarthritis (56.8%), visual impairment (45.2%), high blood pressure (31.4%), and depression (28.8%). Less common disorders included vein insufficiency and hearing impairment. The most prevalent condition among men was visual impairment, while among women, osteoarthritis and related diseases were the most common. Lung disease and stroke were more frequent in men. Heart disease and malignancy had similar prevalences by gender. The remaining conditions were more frequent in women.


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  		Table 2. Prevalence of Chronic Conditions

 
Prevalence of disability on each item of the ADL is shown in Table 3 . Fifty-seven subjects did not usually perform one or more of the activities. The "does not do" category was more frequent with getting outside (4.2%) and use of stairs (3.9%). Among 652 individuals who performed the nine ADLs, 63.2% were independent without difficulty, 21.3% were independent with difficulty in one or more ADL, and 15.5% were dependent in one or more ADL. Disability was most common for the use of stairs (30.6%), followed by bathing (20.2%), walking (20.1%), and getting outside (18.3%). Difficulty was more prevalent than dependence in the use of stairs (21.7%) and walking (15.0%), while dependence was more prevalent than difficulty in bathing (12.4%) and getting outside (11.1%). Disability was the lowest in grooming (5.6%) and eating (3.3%).


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  		Table 3. Disability in Nine Activities of Daily Living

 
Overall, osteoarthritis accounted for 41.8% of the total number of disabilities, and "old age" accounted for 17.1%, followed by heart and lung disease (7.0%) and cerebrovascular disease (5.6%) (Table 4 ). Causes of disability were slightly different in subjects independent with difficulty compared to those who were dependent. Among the dependent, neurologic (cerebrovascular disease and dementia) and sensory disorders (visual) were relatively more relevant (Table 5 ).


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  		Table 4. Self-Reported Causes of Disability in Nine Basic Activities of Daily Living, in Percentages

 

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  		Table 5. Overall Percentage of Self-Reported Causes of Disability in Nine Activities of Daily Living by Level of Disability

 
Table 6 shows the net effect of the selected chronic diseases on the probability of having disability as estimated by odds ratios (ORs). Conditions were ranked according to the magnitude of the association. Cerebrovascular disease was the condition most strongly associated with disability (OR = 3.51, 95% confidence interval [95% CI]: 1.44–8.60), followed by depression and anxiety disorders (OR = 2.72 [1.83–4.05]) and diabetes (OR = 2.18 [1.24–3.83]). By comparison, the associations between more prevalent conditions and disability were less remarkable, including osteoarthritis (rank 6), visual impairment (rank 13), and high blood pressure (rank 9), as shown in Table 6 .


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  		Table 6. Associations Between the Presence of Chronic Diseases and Functional Disability in One or More Activities of Daily Living (n = 652)

 

   Discussion
Top
 Abstract
 Methods
 Results
 Discussion
References
 
To our knowledge, this is one of the few studies attempting to estimate the prevalence of chronic diseases and disability in Spain, and the first that provides information on self-reported causes of disability among Spanish community-dwelling older people. Osteoarthritis and related diseases are the most prevalent chronic conditions and the major perceived cause of disability. However, cerebrovascular disease is the single condition with the largest disabling impact.

At least 96% of persons in our study reported one or more chronic conditions, consistent with a "conservative" estimate of 88% in the United States (9). The prevalence of specific chronic conditions was also similar to overall data from 1983–1986 in the United States (10)(11)(12)(13)(14). Otherwise, the order of prevalence (rank 1 for osteoarthritis, rank 2 for hypertension, followed by sensorial problems and diabetes) appears to be consistent with another published report (15). Another study shows the same pattern of prevalence by gender (11), except that coronary heart disease was more common in men, albeit in our study, the term "heart diseases" also included nonischemic categories of heart disease (e.g., heart failure), which may be more frequent in women.

We found a higher percentage of elderly adults reporting dependence in one or more ADLs compared to other studies (16)(17)(18)(19), but two issues are worth mentioning. First, we have included not only self-care items (originally developed for the assessment of disabled patients), but also mobility items that allow a more comprehensive assessment of a noninstitutionalized community population (1). The higher number of items used surely increases the percentage of people with disability in one or more ADLs. Another explanation comes from the fact that in our population only 15.9% lived alone, half the amount of that in the United States (10)(19)(20). This implies that a higher percentage of subjects can obtain help from younger relatives without needing it, just because they live in the same house or in the vicinity, thus overestimating dependence in our study.

Bathing and getting outside presented the highest prevalence of dependence, while feeding and toileting presented the lowest, according to other studies (16)(17)(19)(21)(22)(23)(24)(25), and also consistent with the hierarchical structure of ADLs, in which ability to feed is the last ADL that an elder is most likely to lose in life.

Osteoarthritis accounted for 41% among self-reported causes of disability in our population, more than any other condition, in accordance to other studies (6)(7)(24)(25). Diseases reported as the main cause of difficulty varied by task: heart and lung disease were cited more often as causes of disability for tasks requiring high aerobic exercise capacity, such as walking, climbing stairs, or getting outside. By comparison, stroke was most commonly reported as a cause of disability for ADLs involving the use of the upper extremities. The same pattern was found in another study (7).

Among self-reported causes of disability, other studies found percentages of older people who attribute disability to "old age" of 11% (7) and 20% (5). In our study, old age was the second self-reported cause of all disabilities (17%). Concern has arisen regarding the negative effect of this fact; if disability is considered equivalent to "old age," and not due to specific diseases or conditions, elderly people may not seek medical care for undiagnosed diseases, contributing to the progression of disability.

Not surprisingly, sensorial and neurological diseases were more often cited as major causes of dependence rather than difficulty. Mental and cognitive consequences of these conditions may additionally increase the risk of dependence. However, osteoarthritis, peripheral vascular disorders, and other ill-defined symptoms (where cognitive status is not involved) occurred more frequently as causes of physical difficulty rather than dependence.

Ranking of relative risks for conditions associated with disability were similar to the results of previous studies (26)(27). Cerebrovascular disease showed the strongest association with disability. Depression and diabetes ranked second and third, respectively; some studies also established an association between these conditions and disability (28)(29)(30)(31)(32). Other prevalent conditions (e.g., hypertension, visual impairment, or vein insufficiency) were not clearly related to disability in our research, nor in other studies (27).

Some characteristics of our study could have limited our results. First, our data are cross-sectional, so causation can only be suggested. Self-reporting may underestimate the prevalence of preclinical disease and may have misclassified some conditions. Additionally, it could be less accurate to attribute disability to specific conditions due to the presence of comorbidity. However, prevalences estimated by this method seem, at least, comparable to those derived from clinical examination (33). Furthermore, the validity of self-report of disease as a cause of functional impairment has been shown elsewhere (7).

In conclusion, as perceived by the older persons themselves, osteoarthritis is the condition that causes the largest percentage of disabilities in the population under study. However, cerebrovascular disease, depression and anxiety disorders, and diabetes are the conditions most clearly related to the presence of disability. Public health policies to identify diseases demanding preventive strategies to maintain the functional status among community dwellers may depend on whether more prevalent but less disabling diseases (e.g., osteoarthritis) or less prevalent but more disabling diseases (e.g., cerebrovascular disease) are considered (11)(26). In this context, policies to prevent osteoarthritis must be a priority considering its high prevalence and involvement in the number of disabilities. On the other hand, though less prevalent, public policies should continue to focus on cerebrovascular disease, mental disorders, and diabetes because of their high impact on disability.


   Acknowledgments
 
This study was supported by Grant FIS 93/0159 from the Spanish Fondo de Investigación Sanitaria. Dr. Valderrama was partially supported by Grant FIS 98/9054 from the Spanish Fondo de Investigación Sanitaria.

We thank Dr. Fernando Rodríguez Artalejo and an anonymous reviewer for their helpful advice in the elaboration of this article.

Received February 20, 2002

Accepted May 6, 2002


   References
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 Abstract
 Methods
 Results
 Discussion
 References
 

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