ABSTRACT:

Introduction:

Functionality in aging is associated with the autonomy and independence of older people.

Objective:

To identify and hierarchize the difficulties reported by older adults in performing activities of daily living.

Method:

This is a cross-sectional, descriptive, household-based study that used the Health, Well-being, and Aging Study (Saúde, Bem-Estar e Envelhecimento - SABE) database of 2000, 2006, and 2010. We evaluated the functionality using reports on the difficulty in performing basic and instrumental activities of daily living (ADL and IADL, respectively). The Guttman scaling assessed the hierarchy of functional impairment.

Results:

The prevalence of reported difficulty in performing one or more IADLs was 35.4, 45.8, and 41.0%; while for ADLs, it was 16.3, 13.3, and 17.5%, in 2000, 2006, and 2010, respectively. In ten years of follow-up, the variability in prevalence among women ranged from 42.3 to 54.6% for IADL impairment, and 17.0 to 20.4% for ADL. For men, it varied from 25.6 to 33.1% for IADL impairment, and 8.0 to 13.7% for ADL. In the three waves, the activities with the highest reported difficulty were using transportation, performing heavy tasks, and managing finances, while feeding was the least prevalent.

Conclusion:

The prevalence of functional impairment increased in ten years, with higher variability among women and with advancing age. These results contribute to the planning of services and adequate distribution of existing resources as they reveal the needs and care required.

Keywords:
Aged; Activities of daily living; Frail elderly

INTRODUCTION

Functional capacity or functionality can be defined as a set of behavioral competencies related to the administration and management of daily life, involving physical integrity, cognitive status, self-regarding actions, emotional state, and running of everyday life in the performance of activities and social roles¹1. Guariento ME, Neri AL. Assistência Ambulatorial ao Idoso. Campinas: Alínea; 2010.. In practice, the functionality of older people is assessed, in most cases, based on their difficulty (reported or observed) in performing basic and instrumental activities of daily living (ADL and IADL, respectively).

ADLs relate to an individual’s self-care capacity, involving the performance of activities such as bathing/showering, dressing, toileting, transferring, ambulating, and feeding from a plate placed in front of the person. IADLs require the active participation of older adults in the community and/or their ability to live alone, including activities such as preparing meals, taking medicines, shopping, managing finances, using the telephone, performing light and heavy household tasks, and using transportation²2. Brasil. Ministério da Saúde. Política Nacional de Saúde da Pessoa Idosa. Portaria MS/GM nº 2.528, de 19 de outubro de 2006. Aprova a Política Nacional de Saúde da Pessoa Idosa [Internet]. Brasília: Ministério da Saúde; 2006 [acesso em 5 dez. 2017]. Disponível em: http://www.saude.mg.gov.br/atos_normativos/legislacao-sanitaria/estabelecimentos-de-saude/atencao-ao-idoso/Portaria_2528.pdf
http://www.saude.mg.gov.br/atos_normativ... .

The proper performance of these activities involves cultural and learning aspects, and demands organized locomotor skills and preserved neurological function³3. Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illness in the aged. The index of ADL: a standardized measure of biological and psychosocial function. JAMA. 1963; 185(21): 914-9.^,44. Moraes EN. Atenção à saúde do Idoso: Aspectos Conceituais. Brasília: Organização Pan-Americana da Saúde; 2012.. The more complex the activity, the greater the need for adjustment, integration, and harmony between the main functional domains (cognition, mood, mobility, and communication)⁴4. Moraes EN. Atenção à saúde do Idoso: Aspectos Conceituais. Brasília: Organização Pan-Americana da Saúde; 2012..

Therefore, beyond the control of chronic conditions, functional capacity must guide the development and adequacy of public policies aimed at this age group⁵5. Pereira JK, Giacomin KC, Firmo JOA. A funcionalidade e incapacidade na velhice: ficar ou não ficar quieto. Cad Saúde Pública. 2015; 31(7): 1451-9. http://dx.doi.org/10.1590/0102-311X00046014
http://dx.doi.org/10.1590/0102-311X00046... .

In turn, functional impairment and disability constitute multifactorial conditions that can affect individuals in different ways and vary in cause, nature, appearance, rhythm, and social implications⁶6. Iezzoni L. Using administrative data to study persons with disabilities. Milbank Q. 2002; 80: 347-79.^,77. Alves LC, Leite IC, Machado CJ. Conceituando e mensurando a incapacidade funcional da população idosa: uma revisão de literatura. Ciên Saúde Colet. 2008; 13(4): 1199-207. http://dx.doi.org/10.1590/S1413-81232008000400016
http://dx.doi.org/10.1590/S1413-81232008... .

When Katz et al.³3. Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illness in the aged. The index of ADL: a standardized measure of biological and psychosocial function. JAMA. 1963; 185(21): 914-9. designed the original instrument of functional assessment- worldwide known and used -, they identified the existence of a certain hierarchy in functional acquisition and loss regarding ADLs. According to the authors, functional reconditioning of older adults followed a sequence comparable to that observed in child development. Also, these functions might have some similarities to the behavior in primitive societies, giving them primary biological and psychological conditions, and reflecting a hierarchy of neurological and locomotor responses³3. Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illness in the aged. The index of ADL: a standardized measure of biological and psychosocial function. JAMA. 1963; 185(21): 914-9.^,88. Duarte YAO, Andrade CL, Lebrão ML. O Índex de Katz na avaliação da funcionalidade dos idosos. Rev Esc Enferm USP. 2007; 41(2): 317-25. http://dx.doi.org/10.1590/S0080-62342007000200021
http://dx.doi.org/10.1590/S0080-62342007... .

Identifying the progression pattern of difficulties in performing activities can be critical for the development of effective interventions that prevent or delay functional decline, in addition to allowing the recognition of subgroups of individuals who could benefit from a targeted intervention⁹9. Bendayan R, Cooper R, Wloch EG, Hofer SM, Piccinin AM, Muniz-Terrera G. Hierarchy and speed of loss in physical functioning: A comparison across older US and English men and women. J Gerontol A Biol Sci Med Sci. 2017; 72(8): 1117-22. https://doi.org/10.1093/gerona/glw209
https://doi.org/10.1093/gerona/glw209... . In this scenario, the purpose of the present study was to identify and hierarchize the difficulties reported by older adults residing in the city of São Paulo in performing activities of daily living in 2000, 2006, and 2010.

METHOD

This is a cross-sectional study that used data from the Health, Well-being, and Aging Study (Saúde, Bem-Estar e Envelhecimento - SABE), collected in 2000, 2006, and 2010.

SABE started as a multicenter survey (2000), at the time coordinated by the Pan American Health Organization, with the purpose of profiling the living and health conditions of older people (≥ 60 years) living in seven urban centers in Latin America and the Caribbean (Buenos Aires in Argentina, Bridgetown in Barbados, Havana in Cuba, Mexico City in Mexico, Montevideo in Uruguay, Santiago in Chile, and São Paulo in Brazil). In São Paulo, a probability sample of 2,143 older people (cohort A₀₀) of both genders was selected, assessed, and interviewed. Silva¹⁰10. Silva NN. Processo de amostragem. In: Lebrão ML, Duarte YAO, eds. O projeto SABE no Brasil: uma abordagem inicial. Brasília: Organização Pan-Americana da Saúde; 2003. brings the sample design details of the initial study.

Since 2006, the cohort A₀₀ was located, and out of the initial total, 1,115 older people were interviewed and reevaluated. The observed difference consisted of deaths (30.3%), refusals (8.2%), relocation (2.4%), institutionalization (0.5%), and people not found (6.5%). A new probability sample of individuals aged 60 to 64 years (a non-existent age range at that moment) was drawn to compose cohort B₀₆ (n = 298), totaling 1,413 older people (≥ 60 years) of both genders interviewed in that year.

In 2010, a third data collection was conducted with 990 older people located, interviewed, and reevaluated, who belonged to cohorts A and B. As in 2006, a new probability sample of individuals aged 60 to 64 years was drawn to compose cohort C₁₀ (n = 355), totaling 1,345 older adults interviewed in that year.

Regarding the period of birth of the older adults under study, cohort A (2000) was born before the Second World War; cohort B, during the war; and cohort C (2010), in the immediate post-war period.

The probability samples of each data collection were constructed to represent the older population living in the city of São Paulo, in their respective years. To accomplish that, sample weights related to the variability between the number of interviews in each sector and some sociodemographic conditions (gender and age) were used, according to the year in question.

Each data collection used the following variables:

The hierarchy of the emergence of reported difficulties in performing activities was based on the scaling proposed by Guttman¹²12. Guttman L. The basis of scalogram analysis. In: Stouffer SA, ed. Measurement and prediction. Nova York: Princeton University Press; 1950. p. 60-90., which first described the proportion of these difficulties reported by older adults, sorting them in descending order. In this scaling, each answer can predict the performance of the previous activity. When the answers do not follow this logic, they are considered “errors,” which this study expressed in proportions. The coefficient of reproducibility (CR) determines the validity of the scaling, measuring the relative fitting degree used to scale the order of activity distribution. We considered CR ≥ 0.9 (90%) as ideal, with the “error” corresponding to 10%, that is, only 10% or fewer errors identified, a proportion regarded as small¹²12. Guttman L. The basis of scalogram analysis. In: Stouffer SA, ed. Measurement and prediction. Nova York: Princeton University Press; 1950. p. 60-90.. This scaling was repeated in the three data collections and subsequently compared between them.

In 2000, SABE was submitted to and approved by the National Committee for Ethics in Research (Comissão Nacional de Ética em Pesquisa - CONEP) (report No. 315/99). In 2006 and 2010, it was submitted to and approved by the Committee for Ethics in Research (Comitê de Ética em Pesquisa - COEP) of Faculdade de Saúde Pública da Universidade de São Paulo (reports No. 83/06 and No. 2.044/10, respectively).

RESULTS

SABE conducted 2,143 interviews in 2000, 1,413 in 2006, and 1,345 in 2010, most of them answered by the older adults themselves. Only 8.9% (2000), 7.4% (2006), and 7.8% (2010) needed supporting or substitute informants. The three data collections show a higher prevalence of women, age between 60 to 69 years, married people, reported schooling from 4 to 7 years, and two or more chronic diseases (Table 1).

The prevalence of reported difficulty in performing one or more IADLs was 35.4% (2000), 45.8% (2006), and 41.0% (2010); while for ADLs, it was 16.3% (2000), 13.3% (2006), and 17.5% (2010). In ten years of follow-up, the variability in prevalence among women ranged from 42.3 to 54.6% for IADL impairment, and 17.0 to 20.4% for ADL. For men, it varied from 25.6 to 33.1% for IADL impairment, and 8.0 to 13.7% for ADL.

In all periods analyzed, advancing age was associated with a worse functional performance for both genders (Table 2).

Table 3 demonstrates the proportion of reported difficulties in performing activities of daily living in 2000, 2006, and 2010. In the three periods, functional decline started with IADL impairment, progressing steadily to ADL. The CR and probability of error found in each year were within limits established as ideal (CR > 0.9). The proportions of difficulty varied between activities: using transportation (17.6-22.7%), performing heavy household tasks (17.7-28.8%), shopping (13.4-17.4%), taking medicines ­(11.3-14.0%), dressing (9.1-12.9%), using the telephone (8.2-12.4%), managing finances (8.4-25.0%), bathing/showering (6.2-7.8%), performing light tasks (5.9-13.2%), preparing meals (5.5-7.2%), ambulating (3.6-5.7%), transferring (4.6-8.8%), toileting (4.5-8.6%), and feeding (2.9-3.6%).

Figure 1 presents the evolution of the functional performance of activities of daily living analyzed in the three cohorts. There were variations in the performance of all activities. Managing finances and performing light tasks had the greatest variations, while feeding had the lowest.

Regarding ADLs, there was an overall worsening in functional impairment for both genders, happening in all activities analyzed among women and in all but feeding and dressing among men (Table 4).

Table 5 shows the prevalence of difficulties with functional performance of IADLs in each period analyzed, stratified by activity, gender, and age. In ten years of follow-up, higher functional impairment was present for most IADLs in the different age groups. Out of the eight activities evaluated, women had a worse performance in 50% of them, and men, in 37.5%.

DISCUSSION

In the present study, the proportion of interviewees with IADL limitations was consistently higher than of those with ADL limitations in all age groups, and for both genders. This result corroborates the expected impairment of functional skills during the aging process: first, physical functional limitations (less serious and more common); then, activities considered more complex (IADLs); and later, the most basic ones related to self-care (ADLs)¹³13. Chatterji S, Byles J, Cutler D, Seeman T, Verdes E. Health, functioning, and disability in older adults-present status and future implications. Lancet. 2015; 385(9967): 563-75. https://doi.org/10.1016/S0140-6736(14)61462-8
https://doi.org/10.1016/S0140-6736(14)61... .

A possible analysis of these results involves the effects of age, period, and cohort¹⁴14. Lin SF, Beck AN, Finch BK, Hummer RA, Master RK. Trends in US older adult disability: exploring age, period, and cohort effects. Am J Public Health. 2012; 102(11): 2157-63. https://doi.org/10.2105/AJPH.2011.300602
https://doi.org/10.2105/AJPH.2011.300602... . The three periods investigated showed a positive gradient between the increase in age and prevalence of difficulty in performing IADLs and ADLs. This finding agrees with another study conducted in high-, middle-, and low-income countries¹⁵15. Beard JR, Officer A, Carvalho IA, Sadana R, Pot AM, Michel JP, et al. The World report on ageing and health: a policy framework for healthy ageing. Lancet. 2016; 387(10033): 2145-54. https://doi.org/10.1016/S0140-6736(15)00516-4
https://doi.org/10.1016/S0140-6736(15)00... . In the United States, IADL impairment increased over 27 years (1982 to 2009) among younger cohorts after adjustments for the effects of time/age, while ADL remained stable¹⁴14. Lin SF, Beck AN, Finch BK, Hummer RA, Master RK. Trends in US older adult disability: exploring age, period, and cohort effects. Am J Public Health. 2012; 102(11): 2157-63. https://doi.org/10.2105/AJPH.2011.300602
https://doi.org/10.2105/AJPH.2011.300602... . According to the authors, the trend found can be explained, on the one hand by technological advances in health care, which is associated with a higher survival of more vulnerable older people; and, on the other, by a possible information bias related to the need to use social insurance, available for the more debilitated in this country.

Similarly to a work by Lin et al.¹⁴14. Lin SF, Beck AN, Finch BK, Hummer RA, Master RK. Trends in US older adult disability: exploring age, period, and cohort effects. Am J Public Health. 2012; 102(11): 2157-63. https://doi.org/10.2105/AJPH.2011.300602
https://doi.org/10.2105/AJPH.2011.300602... , the present study shows that the older people in our midst also have an increasing trend in IADL impairment and stability in ADL for both genders, associated with birth cohorts.

According to Christensen et al.¹⁶16. Christensen K, Thinggaard M, Oksuzyan A, Steenstrup T, Andersen-Ranberg K, Jeune B, et al. Physical and cognitive functioning of people older than 90 years: a comparison of two Danish cohorts born 10 years apart. Lancet. 2013; 382(9903): 1507-13. https://doi.org/10.1016/S0140-6736(13)60777-1
https://doi.org/10.1016/S0140-6736(13)60... , two opposing processes could affect the health of successive cohorts. On the one hand, a later cohort would benefit from the progress in health care resulting in more effective prevention of diseases, better treatments, and benefits of higher living standards, including greater access to education and healthier lifestyles. Such progress would help later cohort members to reach a more advanced age in better health conditions, representing the “success of success”: health improvements earlier in life resulting in healthier cohorts at a more advanced age. On the other hand, due to the lives saved, this later cohort would be larger than the previous.

However, these additional survivors could have relatively weak health and even have died, if they lived in previous cohorts with less favorable living conditions and less access to medical care. This process would be the “failure of success,” as it would reduce the average health of the population after allowing very fragile individuals to reach a more advanced age. For instance, when comparing a Danish cohort born in 1915 with another born in 1905, these authors demonstrated that the younger cohort had better survival rates and performance in cognitive tests and ADLs than the previous one, despite being two years older at the time of evaluation. This finding suggests that more people are aging with better overall performance. If this development continues, future functional issues and care needs of very old people could be lower than expected based on the current load of disability¹⁶16. Christensen K, Thinggaard M, Oksuzyan A, Steenstrup T, Andersen-Ranberg K, Jeune B, et al. Physical and cognitive functioning of people older than 90 years: a comparison of two Danish cohorts born 10 years apart. Lancet. 2013; 382(9903): 1507-13. https://doi.org/10.1016/S0140-6736(13)60777-1
https://doi.org/10.1016/S0140-6736(13)60... .

In addition, César et al.¹⁷17. César CC, Mambrini JVM, Ferreira FR, Lima-Costa MF. Capacidade funcional de idosos: análise das questões de mobilidade, atividades básicas e instrumentais da vida diária via Teoria de Resposta ao Item. Cad Saúde Pública. 2015; 31(5): 931-45. http://dx.doi.org/10.1590/0102-311X00093214
http://dx.doi.org/10.1590/0102-311X00093... pointed out that the measure of functional impairment in population surveys would catch only the most important losses of functional capacity, while the more discreet ones could go unnoticed by the interviewees. In this regard, Cella et al.¹⁸18. Cella D, Riley W, Stone A, Rothrock N, Reeve B, Yount S, et al. The Patient-Reported Outcomes Measurement Information System (PROMIS) developed and tested its first wave of adult selfreportes health outcome item banks: 2005-2008. J Clin Epidemiol. 2010; 63: 1179-94. https://doi.org/10.1016/j.jclinepi.2010.04.011
https://doi.org/10.1016/j.jclinepi.2010.... suggest the application of measuring scales of greater extension in investigations including individuals with different levels of functional impairment. These scales should have a broader spectrum of activities with increasing difficulty, involving mobility, strength, endurance, and cognition.

Bleijenberg et al.¹⁹19. Bleijenberg N, Zuithoff NPA, Smith AK, Wit NJ, Schuurmans MJ. Disability in the individual ADL, IADL, and mobility among older adults: A prospective cohort study. J Nutr Health Aging. 2017; 21(8): 897-903. https://doi.org/10.1007/s12603-017-0891-6
https://doi.org/10.1007/s12603-017-0891-... investigated a prospective Dutch cohort regarding its performance in 15 activities, and found that the advanced ones, which demand a proper physical execution - e.g., traveling -, declined sooner than ADLs, while difficulties with IADLs, which require cognitive abilities - e.g., using the telephone, taking medicines, and managing finances -, developed later than with ADLs - e.g., bathing/showering, dressing, and transferring.

In all waves of the present study, difficulties in carrying out activities directly related to the locomotor system - using transportation, performing household tasks, and shopping - were the most prevalent. It is noteworthy that the second most prevalent illness among older adults in the city of São Paulo is joint disease²⁰20. Bettiol CHO, Dellaroza MSG, Lebrão ML, Duarte YAO, Santos EG. Fatores preditores de dor em idosos do Município de São Paulo, Brasil: Estudo SABE 2006 e 2010. Cad Saúde Pública. 2017; 33(9): e00098416. https://doi.org/10.1590/0102-311X00098416
https://doi.org/10.1590/0102-311X0009841... , which is directly related to the performance of these activities and a worse quality of life, as it restricts their independence and, over time, could compromise their autonomy.

The hierarchy observed in the ten years of follow-up of the SABE Study remains from IADLs to ADLs, despite some variability. Bendayan et al.⁹9. Bendayan R, Cooper R, Wloch EG, Hofer SM, Piccinin AM, Muniz-Terrera G. Hierarchy and speed of loss in physical functioning: A comparison across older US and English men and women. J Gerontol A Biol Sci Med Sci. 2017; 72(8): 1117-22. https://doi.org/10.1093/gerona/glw209
https://doi.org/10.1093/gerona/glw209... found a similar hierarchical pattern of decrease rates when analyzing six ADLs from North-American (HRS) and English (ELSA Study) samples, with a 10-year gap. In both cohorts, feeding had the lowest prevalence and variation over the years, as in the present study.

Progressive functional decline leads to an increase in health care demands, specifically for care needs. Nunes et al.²¹21. Nunes DP, Brito TRP, Corona LP, Alexandre TS, Duarte YAO. Idoso e demanda de cuidador: proposta de classificação da necessidade de cuidado. Rev Bras Enferm. 2018; 71(Supl. 2). http://dx.doi.org/10.1590/0034-7167-2017-0123
http://dx.doi.org/10.1590/0034-7167-2017... proposed a classification of care needs related to older people based on the hierarchy of activities of daily living, stratified into minimum, moderate, and maximum, to adjust the planning and manage healthcare resources.

Care is closely associated with the socioeconomic context - both at micro (families) and macro (funded by society or country) levels -, traditions, politics, and culture²²22. Sjölund BM, Wimo A, Engström M, Von Strauss E. Incidence of ADL Disability in Older Persons, Physical Activities as a Protective Factor and the Need for Informal and Formal Care- Results from the SNAC-N Project. PLoS One. 2015; 10(9): e0138901. http://dx.doi.org/10.1371/journal.pone.0138901
http://dx.doi.org/10.1371/journal.pone.0... , which reinforces the urgent need for establishing long-term care policies.

In the period analyzed, women presented a greater functional impairment when compared to men, which could be due to their longer life expectancy and different health, social, cultural, and economic conditions, as corroborated by other studies²³23. Zunzunegui MV, Alvarado BE, Béland F, Vissandjee B. Explaining health differences between men and women in later life: A cross-city comparison in Latin America and the Caribbean. Soc Sci Med. 2009; 68: 235-42. https://doi.org/10.1016/j.socscimed.2008.10.031
https://doi.org/10.1016/j.socscimed.2008... ^,2424. World Health Organization. World report on ageing and health. Genebra: World Health Organization; 2015.^,2525. Biritwum RB, Minicuci N, Yawson AE, Theou O, Mensah GP, Naidoo N. Prevalence of and factors associated with frailty and disability in older adults from China, Ghana, India, Mexico, Russia and South Africa. Maturitas. 2016; 91: 8-18. https://doi.org/10.1016/j.maturitas.2016.05.012
https://doi.org/10.1016/j.maturitas.2016... .

The World Health Organization, in the publication “Active ageing,” establishes as fundamental goals maintaining autonomy and independence, controlling multiple diseases, providing care, and reducing inequalities during aging²⁶26. World Health Organization. Envelhecimento ativo: uma política de saúde. Brasília: Organização Pan-Americana da Saúde; 2005.. In this context, in 2006, the reprint of the National Health Care Policy for Older People brought a paradigm shift by considering functional capacity as the great divide in the evaluation of older people, classifying them as independent and vulnerable to frailty or frail. Thus, states and cities would have this classification as a basis to reorder and readjust existing services.

A limitation of the present study was the use of self-reported questions in the performance assessment of activities of daily living, which could result in information bias. However, it brings important considerations regarding older people and the organization of public health and social policies.

Due to the fast increase in the older population, maintaining their autonomy and independence should be a priority for the health system and society. The results of the present study show that a standard intervention approach that focuses on older adults’ ADL and/or IADL impairment might not work since functional performance varies with advancing age, between genders, and in different cohorts.

CONCLUSION

The prevalence of difficulty reported by older people in performing ADLs and IADLs increased in the period of ten years (2000 to 2010). The variability in the prevalence of functional ADL and IADL impairment was greater among women when compared to men, and with advancing age. Regarding hierarchy, the activities with the highest reported difficulty were using transportation, performing heavy tasks, and managing finances, while feeding was the least prevalent.

Identifying and prioritizing the difficulties reported by older people in performing activities of daily living help the planning of services and adequate distribution of existing resources as they reveal the needs and care required.

References

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