Risk Factors and Precipitants of Severe Disability Among Community-Living Older Persons
Risk Factors and Precipitants of Severe Disability Among Community-Living Older Persons
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DOI：
10.1001/jamanetworkopen.2020.6021
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发表时间：
2020-06-02
影响因子：
13.8
通讯作者：
Murphy, Terrence E.
中科院分区：
文献类型：
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作者：
Gill, Thomas M.;Han, Ling;Murphy, Terrence E.
这项队列研究评估了与老年人严重残疾相关的潜在危险因素和诱因，这些严重残疾是渐进性的（在>= 2个月内）与灾难性的（从1个月到下一个月）。重要性严重残疾大大降低了生活质量，往往导致长期护理或死亡，但严重残疾的潜在过程尚未得到充分评估。目的评价与进行性（≥ 2个月）和灾难性（1个月至下一个月）严重残疾相关的潜在危险因素和促发因素。设计、设置和参与者前瞻性队列研究于1998年3月至2016年12月在康涅狄格州纽黑文市进行，共有754名年龄在70岁或以上的非残疾社区生活者。数据分析于2018年11月至2019年5月进行。主要结果和测量每18个月评估一次候选风险因素。每月评估功能状态和潜在的诱因，包括导致住院、急诊或活动受限的疾病或损伤。重度残疾被定义为在日常生活的4项基本活动中至少有3项需要个人协助。分析基于18个月间隔内的人月。结果754名参与者的平均（SD）年龄为78.4（5.3）岁，487名（64.6%）为女性，683名（90.5%）为非西班牙裔白色参与者。基于3550个间期，进行性和灾难性重度残疾的发生率分别为3.5%和9.7%。在多因素分析中，6个危险因素与进行性残疾独立相关（≥ 85岁：风险比[HR]，1.6; 95% CI，1.1-2.4;听力损害：HR，1.7; 95% CI，1.0-2.8;虚弱：HR，2.4; 95% CI，1.6-3.7;认知损害：HR，2.0; 95% CI，1.3-3.1;低功能自我效能：HR，1.8; 95% CI，1.2-2.8;低峰值血流：HR，1.7; 95% CI，1.2-2.4），4例与灾难性残疾独立相关（视力损害：HR，1.4; 95% CI，1.1-1.8;听力损害：HR，1.3; 95% CI，1.0-1.7;体能不良：HR，1.8; 95% CI，1.3-2.5;低峰值血流：HR，1.3; 95%CI，1.0-1.7）。促发因素的相关性比危险因素的相关性更明显，住院和灾难性残疾的HR高达321.4（95%CI，194.5-531.0），住院和进行性残疾的HR高达48.3（95%CI，31.0%-75.4%）。消除干预性住院治疗与进行性和灾难性重度残疾风险分别降低3.0%（95% CI，3.0%-3.1%）和12.3%（95% CI，12.1%-12.5%）相关。风险差异为0.6%（95% CI，0.6%-0.6%）和1.3%（95% CI，1.3%-1.4%），急诊科访视和0.1%（95% CI，0.1%-0.2%）和0.4%（95% CI，0.4%-0.4%），范围为0.1%独立危险因素、进行性残疾和灾难性残疾的发生率分别为0.3%（95%CI，0.1%-0.1%）和0.3%（95%CI，0.3%-0.3%）。结论和相关性-这项研究的结果表明，无论是渐进性或灾难性的发展，严重残疾的老年社区生活的成年人最常见的是在设置一个干预性的疾病或伤害。为了减轻严重残疾的负担，需要更积极的努力来预防和管理干预性疾病或伤害，并促进这些衰弱事件后的恢复。问题与严重残疾相关的传统风险因素和干预性疾病或伤害（即，precipants）的相对贡献是什么？结果在这项队列研究中，754名年龄在70岁或以上的非残疾社区生活的人进行了近19年的纵向随访，干预性疾病或严重残疾的伤害的关联比危险因素更为明显，进行性残疾的风险比高达20倍，灾难性残疾的风险比高达177倍。这项研究的结果表明，为了减轻严重残疾的负担，需要采取更积极的措施来预防和管理干预性疾病或伤害，并促进这些使人衰弱的事件后的恢复。
This cohort study evaluates potential risk factors and precipitants associated with severe disability that develops progressively (during >= 2 months) vs catastrophically (from 1 month to the next) in older adults.Importance Severe disability greatly diminishes quality of life and often leads to a protracted period of long-term care or death, yet the processes underlying severe disability have not been fully evaluated. Objective To evaluate potential risk factors and precipitants associated with severe disability that develops progressively (during >= 2 months) vs catastrophically (from 1 month to the next). Design, Setting, and Participants Prospective cohort study conducted in greater New Haven, Connecticut, from March 1998 to December 2016, with 754 nondisabled community-living persons aged 70 years or older. Data analysis was conducted from November 2018 to May 2019. Main Outcomes and Measures Candidate risk factors were assessed every 18 months. Functional status and potential precipitants, including illnesses or injuries leading to hospitalization, emergency department visit, or restricted activity, were assessed each month. Severe disability was defined as the need for personal assistance with at least 3 of 4 essential activities of daily living. The analysis was based on person-months within 18-month intervals. Results The mean (SD) age for the 754 participants was 78.4 (5.3) years, 487 (64.6%) were women, and 683 (90.5%) were non-Hispanic white participants. The incidence of progressive and catastrophic severe disability was 3.5% and 9.7%, respectively, based on 3550 intervals. In multivariable analysis, 6 risk factors were independently associated with progressive disability (>= 85 years: hazard ratio [HR], 1.6; 95% CI, 1.1-2.4; hearing impairment: HR, 1.7; 95% CI, 1.0-2.8; frailty: HR, 2.4; 95% CI, 1.6-3.7; cognitive impairment: HR, 2.0; 95% CI, 1.3-3.1; low functional self-efficacy: HR, 1.8; 95% CI, 1.2-2.8; low peak flow: HR, 1.7; 95% CI, 1.2-2.4), and 4 were independently associated with catastrophic disability (visual impairment: HR, 1.4; 95% CI, 1.1-1.8; hearing impairment: HR, 1.3; 95% CI, 1.0-1.7; poor physical performance: HR, 1.8; 95% CI, 1.3-2.5; low peak flow: HR, 1.3; 95% CI, 1.0-1.7). The associations of the precipitants were much more pronounced than those of the risk factors, with HRs as high as 321.4 (95% CI, 194.5-531.0) for hospitalization and catastrophic disability and 48.3 (95% CI, 31.0%-75.4%) for hospitalization and progressive disability. Elimination of an intervening hospitalization was associated with a decrease in the risk of progressive and catastrophic severe disability of 3.0% (95% CI, 3.0%-3.1%) and 12.3% (95% CI, 12.1%-12.5%), respectively. Risk differences were 0.6% (95% CI, 0.6%-0.6%) and 1.3% (95% CI, 1.3%-1.4%) for emergency department visit and 0.1% (95% CI, 0.1%-0.2%) and 0.4% (95% CI, 0.4%-0.4%) for restricted activity, and ranged from 0.1% (95% CI, 0.1%-0.1%) to 0.3% (95% CI, 0.3%-0.3%) for the independent risk factors, for progressive and catastrophic disability, respectively. Conclusions and Relevance The findings of this study suggest that whether it develops progressively or catastrophically, severe disability among older community-living adults arises most commonly in the setting of an intervening illness or injury. To reduce the burden of severe disability, more aggressive efforts will be needed to prevent and manage intervening illnesses or injuries and to facilitate recovery after these debilitating events.Question What are the relative contributions of traditional risk factors and intervening illnesses or injuries (ie, precipitants) associated with severe disability that develops progressively vs catastrophically? Findings In this cohort study of 754 nondisabled community-living persons aged 70 years or older who were followed longitudinally for nearly 19 years, the associations of intervening illnesses or injuries with severe disability were much more pronounced than those of the risk factors, with hazard ratios up to 20-fold greater for progressive disability and 177-fold greater for catastrophic disability. Meaning The findings of this study suggest that to reduce the burden of severe disability, more aggressive efforts will be needed to prevent and manage intervening illnesses or injuries and to facilitate recovery after these debilitating events.