Abstract

This study aimed to identify the incidence and risk factors for the reduced functional capacity of community-dwelling elderly. A prospective, two-stage cohort study was conducted in 2011 and 2014. The study population consisted of 202 initially independent older adults for the basic activities of daily living. The relative risk (RR) and its respective 95% confidence intervals (CI) were used as a measure of association and were estimated by log-binomial regression with robust variance. The incidence of lower functional capacity was 15.3%. The risk factors for the functional decline were unmarried status (RRadj = 2.75; 95%CI: 1.15–6.57) and depressive symptoms (RRadj = 2.41; 95%CI: 1.15–5.06), even after adjusting for gender, age group, per capita household income, diabetes, use of medication and level of physical activity. The high incidence of reduced functional capacity and its association with marital status and mental health aspects reveals the need to consider such factors in the planning of health actions aimed at maintaining and restoring the functional capacity of the seniors.

Elderly health; Aging; Daily activities; Functional disaos bility

Introduction

Aging is characterized by several changes in the human body and metabolism, which potentially produce reduced individual ability to adapt to the environment ¹1. Ferreira OG , Maciel SC , Silva AO , Santos WS , Moreira MA . O envelhecimento ativo sob o olhar de idosos funcionalmente independentes . Rev. Esc. Enferm . 2010 ; 44 ( 4 ): 1065 - 1069 . . People’s capacity to decide and act on their activities of daily living independently has been considered as functional capacity ²2. Avlund K , Lund R , Holstein BE , Due P . Social relations as determinant of onset of disability in aging . Arch Gerontol Geriatr . 2004 ; 38 ( 1 ): 85 - 99 . . Thus, the basic activities of daily living (BADL) of self-care such as bathing, dressing, using the toilet, feeding, moving and continence have been deemed an essential indicator of the elderly’s functioning ³3. Buurman BM , Van Munster BC , Korevaar JC , de Haan RJ , de Rooij SE . Variability in measuring activities of daily living functioning and functional decline in hospitalized older medical patientes: a systematic review . J Clinc Epidemiol 2011 ; 64 ( 6 ): 619 - 627 . . Lower functional capacity and its implications for the older adults’ health, relatives, and the health system should be taken as an essential issue to be addressed with the advancement of the aging population. According to a study by López et al. ⁴4. López SR , Montero P , Carmenate M , Avendano M . Functional decline over two years in older Spanish adults: Evidence from SHARE . Geriatr Gerontol Int 2014 ; 14 ( 2 ): 403 - 412 . with individuals 65 years of age or older, reduced functional capacity was observed in 11.9% of the elderly. Functional decline is associated with health conditions, such as poor self-perception of health, stroke, diabetes mellitus and heart disease; sociodemographic characteristics, such as being female, age ≥ 80 years, living alone, being widowed, low level of schooling or illiteracy; as well as factors such as sedentary lifestyle and reduced daily activities ⁵5. Barbosa BR , Almeida JM , Rossi BM , Barbosa LAR . Avaliação da capacidade funcional dos idosos e fatores associados à incapacidade . Cien Saude Colet 2014 ; 19 ( 8 ): 3317 - 3325 .^,66. Nunes MC , Ribeiro RCL , Rosado EFPL , Franceschini SC . Influência das características sociodemográficas e epidemiológicas na capacidade funcional de idosos residentes em Ubá, Minas Gerais . Rev. Bras. Fisioter . 2009 ; 3 ( 5 ): 376 - 382 . .

Reduced functional capacity consists of the lack of abilities to provide self-care by the older adults, who, by becoming dependent on relatives or caregivers, produces social, family and health costs that must be investigated. The study of risk factors for impaired functional capacity may contribute to the proposal of policies and interventions that aim at minimizing the impacts caused by the loss of the seniors’ functionality. Thus, this study aimed to identify the incidence and risk factors for lower functional capacity of community-dwelling elderly.

Methods

This prospective cohort study was conducted using data from a population-based epidemiological survey entitled “Nutritional status, risk behaviors and health conditions of the elderly in Lafaiete Coutinho, Bahia”. The study was conducted with older adults living in the municipality of Lafaiete Coutinho, Brazilian State of Bahia, located 356 km off the State capital, with 3,901 inhabitants, spread over urban (53.9%) and rural (46%) areas, all registered under the Family Health Strategy (ESF) ⁷7. Instituto Brasileiro de Geografia e Estatística (IBGE) . Resultados do Censo 2010 . IBGE . 2010 . [ acessado 2015 Maio 15 ]. Disponível: http://www.ibge.gov.br/home/estatistica/populacao/censo2010/tabelas_pdf/total_populacao_bahia.pdf
http://www.ibge.gov.br/home/estatistica/... .

The study population consisted of all non-institutionalized individuals aged 60 years and over, of both genders and living in the urban area. The baseline study was conducted in 2011 (Phase I) with the census of the 355 elderly enrolled in the Family Health Strategy (ESF). Of these, only 260 were considered independent in performing the BADL and were eligible for follow-up. In phase II, in 2014, 202 elderly individuals with responses to the BADL scale were identified, thus resulting in 58 losses (22.3%), which were due to death, moving to another city and not found even after three attempts.

Data were collected through a home interview, and the anthropometric measurements were scheduled and performed at the municipal health facility. A cognitive screening was conducted through the modified and validated version of the Mini-Mental State Examination (MMSE) before the interview, seeking to evaluate the preservation of recent memory to respond to the questionnaires ⁸8. Icaza MC , Albala C . Projeto SABE. Mini mental state examination (MMSE) del estudio de dementia em Chile: análisis estísticos . Brasília : Organização Pan-Americana de Saúde (OPAS) ; 1999 . . The cut-off point was ≥ 13 points (not compromised) and ≤ 12 points (compromised) ⁹9. Bertolucci PHF , Brucki SMD , Capacci SR , Juliano Y . The Mini-Mental State Examination in anout patient population: influence of literacy . Arq Neuro-Psiquiatr 1994 ; 52 ( 1 ): 1 - 7 . . The research was continued with the assistance of an informant for those elderly individuals who scored less than or equal to 12 points. Informants were people residing in the same household and who knew how to provide information about the elderly respondent. Pfeffer’s Functional Activities Questionnaire (FAQ) was applied to informants, continuing the interview with them if the sum of the questionnaire was six or more, and with the elderly, if the sum was five or less ¹⁰10. Pfeffer RI , Kurosaki TT , Harrah Junior CH , Chance JM , Filos S . Measurement of functional activities in older adults in the community . J Gerontol 1987 ; 37 ( 3 ): 323 - 329 . . Thus, the combination of these two instruments, the MMSE and FAQ sought to ensure a higher specificity in the identification of the elderly with a more severe cognitive decline, given the bias produced by low schooling ¹¹11. Brasil . Ministério da saúde (MS) . Envelhecimento e saúde da pessoa idosa . Brasília : MS ; 2007 . ( Série A. Normas e Manuais Técnicos ). .

The questionnaire of the “Health, Welfare and Aging” (SABE) ¹²12. Albala C , Lebrão ML , León DEM , Ham-Chande R , Hennis AJ , Palloni A , Peláez M , Pratts O . Encuesta Salud, Bien estar y Envejecimiento (SABE):metodología de la encuesta y perfil de la población estudiada . Rev Panam Salud Publica 2005 ; 17 ( 5/6 ): 307 - 322 . survey was applied along with the International Physical Activity Questionnaire (IPAQ) ¹³13. Benedetti TRB , Antunes PC , Rodriguez-Añez CR , Mazo GZ , Petroski EL . Reprodutibilidade e validade do Questionário Internacional de Atividade Física (IPAQ) em homens idosos . Rev. Bras. Med. Esporte . 2007 ; 13 ( 1 ): 11 - 16 . , Brazilian extended version. The interview process consisted of a home visit made to search for aspects such as sociodemographic characteristics, health conditions, and behavioral factors. Elderly’s weight and height measurements were performed in two Municipal Family Health Facilities, with prior scheduling. Interviews and direct measurements were performed by trained interviewers and submitted to a calibration process.

Functional capacity was taken as a dependent variable and evaluated through the Katz et al. scale ¹⁴14. Katz S , Ford AB , Moskowitz RW , Jackson BA , Jaffe MW . The index of ADL: a standardized measure of biological and psychosocial function . JAMA . 1963 ; 185 ( 12 ): 914 - 1 , with information about performing the basic activities of daily living (BADL) such as controlling sphincters, bathing, feeding, lying down and getting out of bed, going to the restroom and dressing up. The elderly were asked about the difficulty or need for assistance in each basic activity. Independent people are those reporting no need for help to perform any BADL, and dependent people those reporting requiring help in at least one of the BADLs. Sociodemographic characteristics were considered independent variables: gender (female and male); age group (≥ 60 to ≤ 79, ≥ 80); reads and writes a message (yes, no); marital status (married, unmarried); per capita household income (> 510.00, ≤ 510.00) referring to the minimum wage in 2011 and participation in religious activity (participates, does not participate). Behavioral factors were level of physical activity assessed by IPAQ, long version ¹³13. Benedetti TRB , Antunes PC , Rodriguez-Añez CR , Mazo GZ , Petroski EL . Reprodutibilidade e validade do Questionário Internacional de Atividade Física (IPAQ) em homens idosos . Rev. Bras. Med. Esporte . 2007 ; 13 ( 1 ): 11 - 16 . (≥ 150 minutes of weekly moderate or vigorous physical activity = active and < 150 weekly minutes = insufficiently active) ¹⁵15. Hallal PC , Victora CG , Wells JC , Lima RC . Physical inactivity: Prevalence and associated variables in Brazilian adults . Med. Sci. Sports Exerc . 2003 ; 35 ( 11 ): 894 - 900 . ; alcohol consumption (yes, no); tobacco use (smoker, former smoker, never smoked) and working (yes, no). Previous health conditions were evaluated by depressive symptoms through the 15-item Geriatric Depression Scale (GDS), short version, lack of depressive symptoms (≤ 5 points), and presence of depressive symptoms (> 5 points) ¹⁶16. Almeida OP , Almeida SA . Confiabilidade da versão brasileira da escala de depressão em geriatria (GDS) versão reduzida . Arq. Neuro. psiquiatr . 1999 ; 57 ( 2B ): 421 - 426 . ; a modified and validated version ⁸8. Icaza MC , Albala C . Projeto SABE. Mini mental state examination (MMSE) del estudio de dementia em Chile: análisis estísticos . Brasília : Organização Pan-Americana de Saúde (OPAS) ; 1999 . was used to assess cognitive status by the Mini-Mental State Examination (MMSE), not compromised (≥ 13 points) and compromised (≤ 12 points) ⁹9. Bertolucci PHF , Brucki SMD , Capacci SR , Juliano Y . The Mini-Mental State Examination in anout patient population: influence of literacy . Arq Neuro-Psiquiatr 1994 ; 52 ( 1 ): 1 - 7 . ; self-perception of health was classified as positive (excellent, very good, good) or negative (fair, poor); hospitalization in the last 12 months (none, one or more); diseases referred by some health professional were hypertension, diabetes, and osteoporosis (no, yes); falls in the last 12 months (yes, no); use of medicines (none or one, two or more); (BMI <22 kg/m ² = underweight, 22 kg/m ² ≤ BMI ≤ 27 kg/m ² = adequate and BMI > 27 kg/m ² = overweight) ¹⁷17. American Academy of Family Physicians , American Dietetic Association , National Councilon the Aging . Nutrition screening e intervention resources for health care professionals working with older adults. Nutrition Screening Initiative . Washington : American Dietetic Association ; 2002 . [ acessado2015 Maio 15 ]. Disponível em: < http://www.eatright.org/cps/rde/xchg/ada/hs.xsl/nutrition_nsi_ENU_HTML.htm> .
http://www.eatright.org/cps/rde/xchg/ada... .

Statistical analysis

The sociodemographic, behavioral characteristics and health conditions by functional capacity were distributed by the Pearson chi-square test. The incidence of lower functional capacity was estimated using as numerator new cases of dependents for functional capacity, and the total number of elderly was the denominator. The measure of association was the relative risk estimated by log-binomial regression with a robust covariance matrix, and for statistical inference, the 95% confidence interval was estimated by the Newton-Raphson method. We inserted the statistically significant variables, those with a level of significance equal to or lower than 20% in the bivariate analyses and those of theoretical relevance for the exploratory model in the final multivariate model. The statistical significance level was 5%, and the analyses were performed using the IBM SPSS program (IBM SPSS, 21.0, 2012, Armonk, NY: IBM Corp.). The Research Ethics Committee of the State University of Southwest of Bahia approved the research project. Participation was voluntary, and all study participants signed the Informed Consent Form.

Results

Thirty-one new cases of dependent elderly for functional capacity were identified in a population of 202 follow-up elderly. Thus, the incidence of older adults’ lower functional capacity was 15.3%. Among those who became dependent at the end of follow-up, a higher proportion of unmarried women aged over 80 years who could not read and write, with a per capita income lower than one minimum wage and insufficiently active ( Table 1 ) was observed. According to the elderly’s previous health conditions, we found a higher proportion of dependents among those with depressive symptoms, diagnosed with diabetes and using two or more medicines ( Table 2 ). The incidence of reduced functional capacity was statistically higher among elderly individuals aged 80 years or over (RR = 2.57; 95% CI: 1.37-4.82) and unmarried (RR = 2.71; 95% CI: 1.37-5.36) ( Table 3 ). Among the previous health conditions, a statistically higher decline in functional capacity was observed in the elderly with a history of depressive symptoms (RR = 2.94; 95% CI: 1.48 - 5.82) ( Table 4 ). The multivariate exploratory analysis of the sociodemographic, behavioral and previous health conditions associated with lower functional capacity of the elderly revealed that unmarried elderly individuals with previous depressive symptoms were at higher risk of becoming dependent for daily living activities, regardless of gender, age group, per capita household income, diabetes, use of medicines and level of physical activity ( Table 5 ).

Discussion

Longitudinal studies related to lower functional capacity in the context of aging are still scarce, especially with seniors living in small cities with poor health indicators. The proportion of the elderly in municipalities with up to 5,000 inhabitants is 13.8%, higher than the national rate of 10.8% ¹⁸18. Instituto Brasileiro de Geografia e Estatística (IBGE) . Síntese de Indicadores Sociais , Rio de Janeiro , Estudos e pesquisas . 2010 . Disponível em: http://www.ibge.gov.br/home/estatistica/populacao/condicaodevida/indicadoresminimos/sinteseindicsociais2010/SIS_2010.pdf
http://www.ibge.gov.br/home/estatistica/... . Thus, this study aims to ensure the representativeness of older adults living and residing in similar conditions in the Brazilian northeast.

In this context, the results of this study reveal an incidence of a 15.3% decline in functional capacity in community-dwelling elderly between 2011 and 2014. Seniors without a spouse or partner were at a higher risk of becoming dependent compared to those with a relationship, as well as those with previous history of depressive symptoms when compared to those without symptoms, regardless of factors such as gender, age group, income, diabetes, use of medicines and level of physical activity.A study conducted in Spain with individuals aged 65 years and over found an incidence of functional loss of 11.9% ⁴4. López SR , Montero P , Carmenate M , Avendano M . Functional decline over two years in older Spanish adults: Evidence from SHARE . Geriatr Gerontol Int 2014 ; 14 ( 2 ): 403 - 412 . . Despite the regional, social and cultural differences among the studied populations, similar results were also found in Brazil, in studies by Figueredo et al. ¹⁹19. Figueiredo CS , Assis MG , Silva SLA , Dias RC , Mancini MC . Functional and cognitive changes in community-dwelling elderly: Longitudinal study . Brazilian Journal of Physical Therapy 2013 ; 17 ( 3 ): 297 - 306 . , with an incidence of 12.3%, and Moreira et al. ²⁰20. Moreira LP , Correa CR , Corrente JE , Martin LC , Boas PJFV , Ferreira ALA . Antropométrica, capacidade funcional, e as mudanças de estresse oxidativo em indivíduos idosos de estar da comunidade brasileira. Um estudo longitudinal . Archives of Gerontology Geriatria 2016 ; 66 : 140 - 146 . with 21.35%. However, a study carried out in São Paulo estimated a lower functional capacity in 27.47% of the elderly, and this higher incidence can be explained by the methods used, since the latter included institutionalized elderly, as well as a modified Katz scale ²¹21. Alexandre TS , Corona LP , Nunes DP , Santos JLF , Duarte YAO , Lebrão ML . Gender differences in incidence and determinants of disability in activities of daily living among elderly individuals: SABE study . Archives of Gerontology and Geriatrics 2012 ; 55 ( 2 ): 431 - 443 . .

The elderly without a spouse or partner had a lower functional capacity incidence about 2.7 times higher than the elderly with some relationship, married or living with a partner. Some studies have identified a greater functional decline in single, unmarried and widowed elderly individuals ²²22. Wang D , Jianmin Z , Kurosawa M , Inaba Y , Kato N . Changes in activities of daily living (ADL) among elderly Chinese by marital status, living arrangement, and availability of health care over a 3-year period . Environ Health Prev Med 2009 ; 14 ( 2 ): 128 - 141 .^,2323. Costa SMD . Fatores associados à perda funcional em idosos residentes no município de Maceió, Alagoas . Rev Saude Publica 2011 ; 45 ( 6 ): 1137 - 1144 . . The marital status may be related to the care provided by the partner in the most diverse aspects of life, such as health, food, leisure and occupational activities so that these realms of care can contribute to better functional capacity, or even contribute to its maintenance over time.

Older adults with depressive symptoms were approximately 2.4 times at higher risk of functional capacity impairment than those without such symptoms. Similar results were found by Tomita and Burns ²⁴24. Tomita A , Burns JK . Depression, disability and functional status among community-dwelling older adults in South Africa: evidence from the first South African National Income Dynamics Study . Int J Geriatr Psychiatry 2013 ; 28 ( 12 ): 1270 - 1279 . with seniors in South Africa. Depressive symptoms are often accompanied by other symptoms, such as fatigue, physical weariness, loss of vitality, and unwillingness to perform daily activities ²⁵25. American Psychiatric Association . Diagnostic and statistical manual of mental disorders . 5th ed. Arlington : American Psychiatric Association ; 2013 . , thus directly interfering with functional capacity over time and compromising the effort required to maintain functionality as well as the willingness to perform an activity.

The relationship between mental disorders such as depression, neuronal, hormonal and immune system disorders has been shown as a causal mechanism that may predispose the elderly to other illnesses and even to declining physical health ²⁶26. Turner RJ , Noh S . Deficiência física e depressão: uma análise longitudinal . J Soc Saúde Behav 1988 ; 29 : 23 - 37 . . As an example, the relationship between depression and reduced neurotransmitters such as serotonin, noradrenaline, and dopamine has been identified ²⁷27. Hasler G . Pathophysiology of depression: do we have any solid evidence of interest to clinicians? World Psychiatry 2010 ; 9 ( 3 ): 155 - 161 . . Lower dopamine levels may lead to decreased motor performance and emotional modulation ²⁸28. Ingram DK . Age-related decline in physical activity: generalization ton on humans . Med Sci Sports Exerc 2000 ; 32 ( 9 ): 1623 - 1629 . . Loss of interest or pleasure for almost all activities interferes with the social relationships of the older adults. Thus, social isolation, common in people with depressive symptoms, causes the elderly to participate less in community and religious events, reducing the frequency of making or receiving visits. Decreasing these social relationships compromises the functional performance to perform the basic activities of daily living ³3. Buurman BM , Van Munster BC , Korevaar JC , de Haan RJ , de Rooij SE . Variability in measuring activities of daily living functioning and functional decline in hospitalized older medical patientes: a systematic review . J Clinc Epidemiol 2011 ; 64 ( 6 ): 619 - 627 .^,2929. Kawamoto R , Yoshida O , Oka Y . Factors related to functional capacity in community-dwelling elderly . Geriatrics Gerontol Int 2004 ; 4 : 105 - 110 . . The lack of motivation for social relationships leads to less health care, such as not seeking appropriate treatment and physical inactivity ³⁰30. Armenian HK , Pratt LA , Gallo J , Eaton WW . Psychopathology as a predictor of disability: a population-based follow-up study in Baltimore, Maryland . Am J Epidemiol 1998 ; 148 ( 3 ): 269 - 275 . . Thus, several mechanisms related to the mental health of the elderly may explain lower functional capacity. It is necessary to detail the relative contribution of each of these possible causal ways so that public policies and interventions directed to a better functional capacity of the elderly can be improved.

Longitudinal studies addressing other risk factors for reduced functional capacity should be conducted, especially with a larger population and with a more extended follow-up period. The identification of potentially modifiable risk factors may become a fundamental element for the maintenance and recovery of the functional capacity of the elderly. Thus, actions of the health promotion services should seek the autonomy and independence of the elderly, primarily to perform the basic activities of daily living.

Conclusion

The results of this study indicate that the incidence of lower functional capacity in elderly people living in a community in the Northeast of Brazil was 15.3%, and the main risk factors found were being unmarried and having depressive symptoms, regardless of gender, age group, income, diabetes, use of medicines and level of physical activity.

Acknowledgments

We wish to thank the Foundation for Research Support of the State of Bahia (FAPESB) for the financing of the original project and the scientific initiation grant to one of the authors.

References

Publication Dates

History