Developing Rehabilitative Strategies for Disability Prevention in Primary Care

描述(由首席调查员提供)：行动不便问题影响着所有70岁或以上的美国人中的四分之一。以初级保健为基础的活动能力测试一直被认为是一项重要的临床测试，用于识别那些随后活动能力下降和残疾的风险人群。理想情况下，对有风险的人进行康复应该解决导致行动能力下降的主要原因。我们将这些定义为康复障碍，并确定了9种康复障碍，涵盖了当代康复计划中最常见的焦点。认识到其中许多因素是相互关联的，我们以前的工作和经验表明，康复障碍包括四个不同的类别(力量、速度、稳定性和能力)，我们称之为康复损害领域(RID)。我们假设，最常见的疾病和活动能力下降之间的最终共同途径将以不同的RID呈现模式为特征。令人惊讶的是，鉴于行动不便及其临床重要性很高，没有关于行动危险因素筛查和干预的既定行动护理指南，以此作为预防老年初级保健患者残疾的一种手段。对于容易疲劳和虚弱的老年患者，最佳的活动康复应该针对少数RID和RID组合，这些组合是导致活动能力下降的主要原因。然而，如果没有更好的证据来确定通过康复优先考虑哪些损伤和非身体因素，康复护理将不可避免地更多地是一门艺术，而不是一门科学--依赖于个人从业者的主观观点和经验。相比之下，随着对目标风险因素的更清楚了解，康复护理可以成为成功的以初级保健为基础的残疾预防战略的重要组成部分。我们建议对420名65岁及以上表现为临床前残疾的初级保健患者进行前瞻性队列研究。经过2年的跟踪，我们计划评估这9种康复损伤，以确定导致衰退和残疾的不同RID模式。初步工作表明，力量、速度、稳定性和能力的特点可能是最主要的原因。这项调查将针对三个具体目标：(1)在基线，我们将检查这9种康复障碍所代表的RID，并评估什么RID模式与通过晚年功能和残疾工具(LLFDI)的功能成分衡量的当前行动能力受限有关；(2)我们将测试在基线出现的RID和RID组合预测未来两年内以LLFDI的功能成分衡量的行动能力下降；(3)我们将测试基线存在的RID和RID组合预测两年内以LLFDI的残疾成分衡量的残疾进展。填补这一知识空白将有助于制定以初级保健为基础的康复战略，以预防残疾。与公共卫生相关的行走、爬楼梯和其他基本行动任务的困难几乎影响到65岁以上的四分之一的成年人，并预示着跌倒、住院甚至死亡等问题。我们的研究将确定哪些可通过康复纠正的身体因素是老年初级保健患者活动能力恶化的最主要原因。结果将导致对康复作为预防老年人残疾的一种手段的使用进行评估的研究。

DESCRIPTION (provided by principal investigator): Mobility problems affect 1/4 of all Americans aged 70 years or older. Primary care--based mobility testing has been advocated as an important clinical test for identifying those at risk for subsequent mobility decline and disability. Ideally, rehabilitation for those at risk should address the impairments that are most responsible for mobility decline. We define these as Rehabilitative Impairments and have identified 9 rehabilitative impairments as encompassing the most common foci of contemporary rehabilitation programs. In recognizing that many of these factors are interrelated, our previous work and experience suggests that rehabilitative impairments are encompassed within four distinct categories (Strength, Speed, Stability and Capacity), which we refer to as Rehabilitative Impairment Domains (RID). We hypothesize that the final common pathway between the most common medical conditions and mobility decline will be characterized by differing patterns of RID presentation. Surprisingly, given the high prevalence of mobility limitations and their clinical importance, there are no established mobility care guidelines concerning mobility risk factor screening and intervention as a means of preventing disability among older primary care patients. For older patients vulnerable to fatigue and frailty, optimal mobility rehabilitation should be directed toward those few RID and RID combinations most responsible for mobility decline. However, without better evidence determining which impairments and nonphysical factors to prioritize through rehabilitation, rehabilitative care will inevitably be more "an art than a science" - dependent on the subjective views and experiences of individual practitioners. In contrast, with a clearer understanding of the risk factors to target, rehabilitative care can be a vital component of a successful primary-care based disability prevention strategy. We propose to conduct a prospective cohort study among 420 primary care patients, aged 65 years and older that manifest preclinical disability. Over 2 years of follow up, we plan to evaluate these 9 rehabilitative impairments identifying the distinct RID patterns most responsible for decline and disability. Preliminary work suggests that RID characteristic of Strength, Speed, Stability and Capacity may be most responsible. This investigation will address three specific aims: (1) At baseline, we will examine the RID represented by these 9 rehabilitative impairments and evaluate what patterns of RID are associated with current mobility limitation as measured by the Function component of the Late Life Function and Disability Instrument (LLFDI); (2) We will test which RID and RID combinations presenting at baseline predict future decline in mobility function as measured by the Function component of the LLFDI over two years; (3) We will test which RID and RID combinations present at baseline predict the progression of disability as measured by the Disability components of the LLFDI over two years. Filling this knowledge gap will allow for the development of primary care-based rehabilitative strategies to prevent disability. PUBLIC HEALTH RELEVANCE Difficulty with walking, climbing stairs and other basic mobility tasks affect almost 1/4 of adults over the age of 65 years and are predictive of such problems as falls, hospitalizations and even death. Our study will identify which physical factors, correctable through rehabilitation, are most responsible for worsening mobility among older primary care patients. The results will lead to studies evaluating the use of rehabilitation as a means of preventing disability among older adults.