6
Factors associated with functional ability in Brazilian elderly Clarissa de Matos Nascimento a, *, Andre ´ ia Queiroz Ribeiro a , Rosa ˆngela Minardi Mitre Cotta a , Francisco de Assis Acurcio b , Sergio Viana Peixoto c , Silvia Eloiza Priore a , Sylvia do Carmo Castro Franceschini a a Departament of Nutrition and Health, Federal University of Vic ¸osa, Avenue PH Rolfs, Campus Universita ´rio, ZP 36570-000 Vic ¸osa, Minas Gerais, Brazil b Faculty of Pharmacy, Departament of Social Pharmacy, Avenue Anto ˆnio Carlos 6627, Room 1048, Bloco 2, Federal University of Minas Gerais, ZP 31270-000 Belo Horizonte, Minas Gerais, Brazil c Nursing School, Federal University of Minas Gerais, Alfredo Balena Avenue 190, ZP 30130-100 Belo Horizonte, Minas Gerais, Brazil 1. Introduction Aging is associated with increased vulnerability to chronic health problems and decreases in physiological activity. Chronic diseases, disabilities and other health problems frequently occur in a progressive and irreversible way. These factors tend to accumulate and complicate the health status and quality of life of the elderly (Landi et al., 2010; WHO, 2011). In 2001, the World Health Organization (WHO) redefined the concept of disability using the International Classification of Functioning, Disability and Health (ICF). The ICF covers health and welfare from the perspective of the human body, the individual and society. In this new classification, the authors defined or perceived disability as the interaction between health conditions (diseases, trauma, etc.), and contextual factors (personal and environmental factors). Disability involves the inabilities, limita- tions or restrictions of capacity (WHO, 2002). Functional ability is often measured by report of difficulty or need of help to perform Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) (Katz et al., 1963; Lawton and Brody, 1969). ADLs consist of self-care skills like feeding, bathing and/or going to the bathroom (Katz et al., 1963). The IADL is based on tasks that allow independent living in the community, for example shopping, telephoning, using transporta- tion, doing housework, preparing meals and handling money (Lawton and Brody, 1969). With a rapidly aging population, disability has become a public health problem and an important indicator of elderly health and in Brazil, this is a growing field of study. Disability compromises quality of life and increases use of health services, besides being associated with higher mortality in the elderly (Stuck et al., 1999; Maciel and Guerra, 2008; Landi et al., 2010; WHO, 2011). It is therefore important to identify possible determinants of disability in order to better understand how to prevent or delay its onset. Some international and Brazilian studies show that age, lower level of schooling, lower income, female gender, low physical activity, morbidity and hospitalizations are among the determinants of functional disability (Picavet and Van Den Bos, 1997; Santos et al., Archives of Gerontology and Geriatrics 54 (2012) e89–e94 ARTICLE INFO Article history: Received 29 March 2011 Received in revised form 19 June 2011 Accepted 11 August 2011 Available online 16 September 2011 Keywords: Functional ability Elderly Health conditions ABSTRACT The purpose of this observational study, designed as a cross-sectional sample of 621 elderly residents in Vic ¸osa, Minas Gerais state, Brazil was to evaluate the prevalence of inadequate functional ability and associated factors in Brazilian elderly. Interviews were conducted at study subjects’ houses using a questionnaire focused on socio demographic information and health conditions. Elderly who reported some difficulty in performing six or more activities, or total inability to carry out at least three activities identified on the scale developed by Katz et al. (1963) and Lawton and Brody (1969) were considered to have inadequate functional ability. Data analysis included frequency distribution, bivariate and multivariate Poisson regression. The prevalence of inadequate functional ability was of 16.2% (95% CI: 13–19%) in the sample analyzed. With aging, there was a significant trend of inadequate functional ability increasing in men (x 2 for trend = 8.481; p = 0.003) and women (x 2 trend = 13.667; p < 0.001). Factors positively associated with inadequate functional ability were age over 80 years, low monthly income, poor self-health perception, history of hospitalization in the last year, use of 5 or more medicines in the last 15 days; history of depression, history of osteoporosis, and negatively associated to physical activity. Factors associated with inadequate functional ability highlighted in this study demonstrate the importance of health programs in Brazil focused on adults and the elderly in preventing or delaying functional decline and promote healthy aging. ß 2011 Elsevier Ireland Ltd. All rights reserved. * Corresponding author. Tel.: +55 318699 4596. E-mail address: [email protected] (C.d.M. Nascimento). Contents lists available at SciVerse ScienceDirect Archives of Gerontology and Geriatrics journal homepage: www.elsevier.com/locate/archger 0167-4943/$ – see front matter ß 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.archger.2011.08.005

Factors associated with functional ability in Brazilian elderly

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Page 1: Factors associated with functional ability in Brazilian elderly

Archives of Gerontology and Geriatrics 54 (2012) e89–e94

Contents lists available at SciVerse ScienceDirect

Archives of Gerontology and Geriatrics

journa l homepage: www.e lsev ier .com/ locate /archger

Factors associated with functional ability in Brazilian elderly

Clarissa de Matos Nascimento a,*, Andreia Queiroz Ribeiro a, Rosangela Minardi Mitre Cotta a,Francisco de Assis Acurcio b, Sergio Viana Peixoto c, Silvia Eloiza Priore a,Sylvia do Carmo Castro Franceschini a

a Departament of Nutrition and Health, Federal University of Vicosa, Avenue PH Rolfs, Campus Universitario, ZP 36570-000 Vicosa, Minas Gerais, Brazilb Faculty of Pharmacy, Departament of Social Pharmacy, Avenue Antonio Carlos 6627, Room 1048, Bloco 2, Federal University of Minas Gerais, ZP 31270-000 Belo Horizonte, Minas

Gerais, Brazilc Nursing School, Federal University of Minas Gerais, Alfredo Balena Avenue 190, ZP 30130-100 Belo Horizonte, Minas Gerais, Brazil

A R T I C L E I N F O

Article history:

Received 29 March 2011

Received in revised form 19 June 2011

Accepted 11 August 2011

Available online 16 September 2011

Keywords:

Functional ability

Elderly

Health conditions

A B S T R A C T

The purpose of this observational study, designed as a cross-sectional sample of 621 elderly residents in

Vicosa, Minas Gerais state, Brazil was to evaluate the prevalence of inadequate functional ability and

associated factors in Brazilian elderly. Interviews were conducted at study subjects’ houses using a

questionnaire focused on socio demographic information and health conditions. Elderly who reported

some difficulty in performing six or more activities, or total inability to carry out at least three activities

identified on the scale developed by Katz et al. (1963) and Lawton and Brody (1969) were considered to

have inadequate functional ability. Data analysis included frequency distribution, bivariate and

multivariate Poisson regression. The prevalence of inadequate functional ability was of 16.2% (95% CI:

13–19%) in the sample analyzed. With aging, there was a significant trend of inadequate functional

ability increasing in men (x2 for trend = 8.481; p = 0.003) and women (x2 trend = 13.667; p < 0.001).

Factors positively associated with inadequate functional ability were age over 80 years, low monthly

income, poor self-health perception, history of hospitalization in the last year, use of 5 or more medicines

in the last 15 days; history of depression, history of osteoporosis, and negatively associated to physical

activity. Factors associated with inadequate functional ability highlighted in this study demonstrate the

importance of health programs in Brazil focused on adults and the elderly in preventing or delaying

functional decline and promote healthy aging.

� 2011 Elsevier Ireland Ltd. All rights reserved.

1. Introduction

Aging is associated with increased vulnerability to chronichealth problems and decreases in physiological activity. Chronicdiseases, disabilities and other health problems frequently occur ina progressive and irreversible way. These factors tend toaccumulate and complicate the health status and quality of lifeof the elderly (Landi et al., 2010; WHO, 2011).

In 2001, the World Health Organization (WHO) redefined theconcept of disability using the International Classification ofFunctioning, Disability and Health (ICF). The ICF covers health andwelfare from the perspective of the human body, the individualand society. In this new classification, the authors defined orperceived disability as the interaction between health conditions(diseases, trauma, etc.), and contextual factors (personal andenvironmental factors). Disability involves the inabilities, limita-tions or restrictions of capacity (WHO, 2002).

* Corresponding author. Tel.: +55 318699 4596.

E-mail address: [email protected] (C.d.M. Nascimento).

0167-4943/$ – see front matter � 2011 Elsevier Ireland Ltd. All rights reserved.

doi:10.1016/j.archger.2011.08.005

Functional ability is often measured by report of difficulty orneed of help to perform Activities of Daily Living (ADL) andInstrumental Activities of Daily Living (IADL) (Katz et al., 1963;Lawton and Brody, 1969). ADLs consist of self-care skills likefeeding, bathing and/or going to the bathroom (Katz et al., 1963).The IADL is based on tasks that allow independent living in thecommunity, for example shopping, telephoning, using transporta-tion, doing housework, preparing meals and handling money(Lawton and Brody, 1969).

With a rapidly aging population, disability has become a publichealth problem and an important indicator of elderly health and inBrazil, this is a growing field of study. Disability compromises qualityof life and increases use of health services, besides being associatedwith higher mortality in the elderly (Stuck et al., 1999; Maciel andGuerra, 2008; Landi et al., 2010; WHO, 2011). It is thereforeimportant to identify possible determinants of disability in order tobetter understand how to prevent or delay its onset. Someinternational and Brazilian studies show that age, lower level ofschooling, lower income, female gender, low physical activity,morbidity and hospitalizations are among the determinants offunctional disability (Picavet and Van Den Bos, 1997; Santos et al.,

Page 2: Factors associated with functional ability in Brazilian elderly

C.M. Nascimento et al. / Archives of Gerontology and Geriatrics 54 (2012) e89–e94e90

2007; Fielder and Peres, 2008; Giacomin et al., 2008; Balzi et al.,2010). However, the available knowledge about the epidemiology offunctional disability comes mainly from studies conducted indeveloped countries or in big cities of developing countries, whosecultural and sociogeographical realities are a lot different from thereality of smaller municipalities that are the majority within Brazil.Given the above, the present study aimed to evaluate the prevalenceof inadequate functional ability and associated factors among theelderly in Vicosa, MG, Brazil. Understanding the disability epidemi-ology can enhance country efforts to remove disabling barriers andprovide appropriate services for people with disabilities.

2. Subjects and methods

This was an observational study with a cross-sectionaldesigned, conducted in the municipality of Vicosa, Minas Gerais(MG) state, Brazil, from June to December 2009 with elderly aged60 and older. The Department of Nutrition and Health, atUniversidade Federal de Vicosa (Vicosa’s Federal University)conducted this research. The town of Vicosa, located in the areacalled Zona da Mata of Minas Gerais state had, in 2007, a populationof about 70,404 inhabitants, with 7034 aged 60 years and older.Among those, 55.4% are female. In regard the age groupdistribution, 53.7% of elderly are between 60 and 69 years oldand 31.5% between 70 and 79 years old (DATASUS, 2011).

The target population for this study consisted of elderly peopleaged 60 years or older, living in urban and rural Vicosa (MG). Thisgroup was surveyed during ‘‘The National Campaign for ElderlyVaccination’’ from April to May 2008. With the aim of identifyingnon-participants in the vaccination campaign, the campaign’sdatabase was merged with other databases, namely: Database ofthe Vicosa’s, Federal University employees, active and retired, theregisters of the municipality’s health services, such as ElderlyHealth Program (PSF), Physiotherapy service, the Center ofWomen’s Health, Psychosocial Services, Care Unit, HiperDia andthe Polyclinic. This merged data aimed to identify older peoplewho had not participated in the 2008 vaccination campaign tocomplement the database. After combination of these lists, 7980people aged 60 and over were identified and this number formedthe basis for obtaining the sample. The institutionalized elderlywere excluded from the sample.

The sample size calculation was performed considering thereference population of 7980 elderly, confidence level of 95% andestimated prevalence of 50% and 4.0% of error. From theseparameters, the minimum final sample would be 558 elderlypeople, to which was added 20% to cover potential losses, totaling670 elderly people being studied. Some information was lost due tosubject refusal to participate and unavoidable reasons thatinterviews could not be conducted. Losses were consideredinevitable in situations where randomly selected individuals haddied; had an address that could not be located; or had moved toother locations which were either difficult to find or in othermunicipalities. Thus, 621 elderly were actually assessed. Thesample distribution by gender and age group was similar to theobserved for the elderly population in the municipality of Vicosa.

The interviews were conducted at each elderly’s home, andpreferably pre-scheduled with the sample’s selected interviewees.However, when medical reasons prevented the interview, likedeafness or cognitive disabilities, interviews were conducted in thepresence of relatives or caregivers, who also provided information(except in self-evaluation). The information for this study wasobtained using semi-structured questionnaires that elicited socio-demographic variables: age, gender (male and female), education(never studied; <4 years of schooling; �4 years of schooling) andmonthly income was categorized accordingly to the quartiles ofthe distribution; life habits: physical activity (yes or no); use of

health services: number of physician visits in the last 12 months(none; 1–5 times and 6 or more times), number of hospitalizationsin the last 12 months (none, one or more times); indicators ofhealth status: self-reported health (very good/good, fair, poor/verypoor), number of medications consumed in the last 15 days (until4; 5 or more). Proof of use of most medication was taken underphysicians’ prescription or advice. We assessed the presence ofmorbidity by asking participants if they had ever been diagnosedby a physician or other health professional with any of 14 targetconditions (hypertension, diabetes, osteoporosis, depression,stroke, hearing problems, vision problems, dyslipidemia, asth-ma/bronchitis, arthritis/arthrosis, renal disease, cancer, myocardicinfarction, angina pectoris). Moreover, among the 12 morbiditiesdefined, four were considered of interest: diabetes, depression,arthritis/arthrosis and osteoporosis. These morbidities seems to bemore closely related to functional disability, according to theliterature (Srivastava and Deal, 2002; Rosa et al., 2003; Rodrigueset al., 2009; James et al., 2011; WHO, 2011).

To evaluate the functional ability, a self-assessment scale with12 types of activities was used; it included ADLs and IADLs. ForADLs, the scale developed by Katz et al. (1963) was used, andincluded the following activities: bathing, dressing, eating,toileting, walking from one room to another within home andtransferring from bed to chair. As for the IADLs, the followingactivities were considered: preparing or cooking food, using thephone, leaving the house or taking a bus, taking medication,managing money, shopping, cleaning the house, doing crafts andwashing and ironing (Lawton and Brody, 1969).

The assessment of the ability to perform the 14 activitiesanalyzed was divided into the following categories: 1. has nodifficulty, 2. has little difficulty, 3. has great difficulty, 4. not able,and 5. not applicable. Subsequently, these categories were addedup. For purposes of statistical analysis functional ability wasdichotomized as adequate or inadequate, according to methodologyproposed by Fielder and Peres (2008). Thus, those individuals whoreported some difficulty performing six or more activities (catego-ries 2 and 3) or when the individual reported that at least threeactivities of 12 considered were difficult to perform (category 4)were considered to have inadequate functional ability.

A descriptive analysis of variables of interest was conducted. Thedependent variable was functional ability (adequate or inadequate).The independent variables included sociodemographic (age,education and monthly income) and use of health services andhealth conditions (self-perceived health, number of physician visitsand number of hospitalizations in the last 12 months, number ofmedications consumed in the last 15 days, physical activity,number of morbidities, history of diabetes, depression, arthritis/arthrosis and osteoporosis). Bivariate relationships were examinedby calculating appropriate measures of association. The chi-squarefor linear trend was used to compare the prevalence of functionalability according to the age group between genders. The Pearson’schi-square test was used to compare the prevalence of functionalability according to the categories of independent variables.Multivariate analysis was performed using the Prevalence Ratiosestimates (PR) and the corresponding 95% confidence intervals,obtained from the Poisson regression model with robust variance toidentify the factors independently associated with inadequatefunctional ability Variables that were associated with inadequatefunctional ability in the bivariate analysis with a significance levelof p < 0.20 were included in the multivariate model. Backwardstepwise elimination was used in the Poisson regression, testing forthe significance of elimination of the variable at each stage. Theindependent variables that were associated with the dependentvariable in level below than 0.05 remained in the final model. Thevariables age and gender were kept in the final model due to theirepidemiological significance.

Page 3: Factors associated with functional ability in Brazilian elderly

Table 1Sociodemographic and health characteristics of the elderly study participants.

Vicosa, Minas Gerais state, Brazil, 2009.

Variable n %

Gender

Male 290 46.7

Female 331 53.3

Age (years)

60–69 311 50.1

70–79 216 34.8

�80 94 15.1

Schooling (years)

Never studied 94 15.1

<4 397 64.0

�4 129 20.8

NIa 1 0.1

Monthly income (quartiles) per elderly

1st (U$ 0–251.93) 72 11.6

2nd (U$ 251.94–283.08) 234 37.7

3rd (U$ 283.09–797.79) 153 24.6

4th (�U$ 797.80) 153 25.6

NIa 9 1.4

Self-reported of health

Very good/good 272 43.80

Fair 289 46.54

Poor/very poor 38 6.12

NIa 22 3.54

Number of medications consumed in the last 15 days

Until 4 397 63.9

5 or more 224 36.1

Number of physician visits in the last 12 months

None 45 7.3

1–5 times 449 72.3

6 or more times 126 20.3

NIa 1 0.1

Number of hospitalizations prior to the interview

None 526 84.7

One or more times 94 15.2

NIa 1 0.1

Number of morbidities

Until 4 385 62.0

5 or more 236 38.0

History of diabetes 139 22.4

History of depression 117 18.8

History of arthritis/arthrosis 149 24.0

History of osteoporosis 94 15.2

Functional ability

Adequate 519 83.6

Inadequate 100 16.1

NIa 2 0.3

Physical activity

Yes 186 30.0

No 435 70.0

a NI: not informed.

C.M. Nascimento et al. / Archives of Gerontology and Geriatrics 54 (2012) e89–e94 e91

Data have been stored in Epi Info software version 6.04 andanalyzed with the SPSS version 17.0 (SPSS Inc., Chicago, USA)softwares.

The study was approved by the Ethics Committee on HumanResearch of Universidade Federal de Vicosa. Participants received aterm of informed consent, in writing, where the agreement wasrecorded by signature or fingerprint.

3. Results

Among the 621 study participants, the majority was female(53.3%), aged 60–69 years (50.1%) and had less than 4 years ofschooling (64.0%). Almost 38% of the elderly belong to the 2ndquartile of income (U$ 251.94–283.08). Regarding health indica-tors, most interviewees considered their health as fair (48.2%), hadconsulted a physician up to 5 times in the previous year (72.4%),had not been admitted to a hospital unit (84.8%) and reportedhaving up to four diseases (62.0%). More than 35% of seniorsreported using five or more drugs in the period and most ofinterviewees did not practice physical activity (70.0%) and wereconsidered to have adequate functional ability (83.8%) (Table 1).

The prevalence of inadequate functional ability in the studysample was 16.2% (95% CI: 13.0–19.0%). Fig. 1 shows the prevalenceof inadequate functional ability according to gender and age group.This was significantly higher (p = 0.005) among women (20.1%)compared to men (11.7%) and there was a trend of significantincrease according to age among both men (x2 trend = 8.481;p = 0.003) and women (x2 trend = 13.667; p < 0.001).

Table 2 presents the association between sociodemographiccharacteristics and health status with inadequate functionalability. The prevalence of inadequate functional ability wassignificantly higher among women aged 80 years or more, andamong the illiterate elderly with monthly income less than orequal to median. With regard to health conditions, among thosewho reported a poorer perception of health the prevalence ofinadequate functional ability was higher. Higher prevalence wasalso observed among those who used five or more drugs and thosewho did not exercise compared to their counterparts, with thesedifferences being statistically significant. A higher number ofmedical consultations in the past year, history of hospitalization inthis period, report of 5 or more diseases, as well as history ofdiabetes, depression, arthritis/arthrosis and osteoporosis were alsosignificantly associated with inadequate functional ability.

The results of multivariate analysis (Table 3) of the associationbetween sociodemographic characteristics and health status andinadequate functional ability show that the factors independentlyassociated with inadequate functional ability were: age equal to orolder than 80 years, monthly income less than or equal to median,fair, poor/very poor health’s self-assessment, history of hospitali-zation in the last 12 months, use of 5 or more medications in thelast 15 days, history of depression and a history of osteoporosis.Physical activity was negatively and significantly associated withinadequate functional ability.

4. Discussion

In this study, we observed that 16.2% of elderly had inadequatefunctional ability indicating a good degree of autonomy. In the UK,in a study conducted in 1988/1989 less than 10% of people aged55–69 years had the most severe score for disability (Grundy andGlaser, 2000). In the Netherlands, data from national health surveyof 1992 show that 20.5% of elderly had functional disability(Picavet and Van Den Bos, 1997). Moreover, in Santa Catarina state,Brazil, in a study conducted in 2003/2004, the prevalence ofdisability was 37.1% among persons aged 60 and over (Fielder andPeres, 2008). Parahyba and Veras (2008) conducting a temporal

analysis of data from the Brazilian’s National Survey by HouseholdSampling (PNAD) of 1998 and 2003, observed a reduction in theprevalence of disability in all genders and age groups of Brazilianelderly. It is noteworthy that the differences in prevalence ofdisability among the aforementioned studies could be partiallyattributed to the different types of instruments used to assessfunctional ability, as well as the age limits selected to define‘‘elderly,’’ which complicates comparison.

In this study, the prevalence of disability was higher amongwomen, but this difference disappeared in the final model, andgender was not independently associated with functional ability.Investigations on functional disability in older adults have shownconflicting results, with some studies indicating greater disability

Page 4: Factors associated with functional ability in Brazilian elderly

[(Fig._1)TD$FIG]

Inadequate Func�onal Ability (%)

30.3

20.9

36.1

8.610.5

13.3

60-69 years 70-79 years ≥80 years

Men Woman

Fig. 1. Inadequate functional ability.

Table 2Results of the association between sociodemographic health conditions variables

and functional ability among elderly participants study. Vicosa, Minas Gerais state,

Brazil, 2009.

Variables Functional ability to perform

ADL and IADL

p

Adequate Inadequate

Gender

Male 256 (88.3%) 34 (11.7%) 0.005

Female 263 (79.9%) 66 (20.1%)

Age (years)

60–69 276 (89.0%) 34 (11.0%)a <0.001

70–79 181 (84.2%) 32 (15.8%)b

�80 62 (66.0%) 100 (34.0%)c

Schooling (years)

Never studied 70 (74.5%) 24 (25.5%)d 0.001

<4 329 (83.3%) 66 (16.7%)e

�4 120 (93.0%) 9 (7.0%)f

Monthly income per elderly

1st (U$ 0–251.93) 142 (92.8%) 11 (7.2%) <0.001

2nd (U$ 251.94–283.08) 138 (90.2%) 15 (9.8%)

3rd (U$ 283.09–797.79) 179 (76.5%) 55 (23.5%)

4th (>U$ 797.80) 56 (80.0%) 14 (20.0%)

Self-reported of health

Very good/good 259 (95.6%) 12 (4.4%)g <0.001

Fair 240 (83.3%) 48 (16.7%)h

Poor/very poor 17 (44.7%) 81 (55.3%)i

Number of medications consumed in the last 15 days

Until 4 354 (89.4%) 42 (10.6%) <0.001

5 or more 165 (74.0%) 58 (26.0%)

Number of physician visits in the last 12 months

None 42 (93.3%) 3 (6.7%)j <0.001

1–5 times 390 (87.1%) 58 (12.9%)l

6 or more times 86 (68.8%) 39 (31.2%)m

Number of hospitalizations in the last 12 months

None 461 (88.0%) 63 (12.0%) <0.001

One or more times 57 (60.6%) 37 (39.4%)

Number of morbidities

Until 4 350 (90.9%) 35 (9.1%) <0.001

5 or more 169 (72.2%) 65 (27.8%)

History of diabetes

Yes 101 (72.7%) 38 (27.3%) <0.001

No 418 (87.1%) 62 (12.9%)

History of depression

Yes 87 (74.4%) 30 (25.6%) 0.002

No 432 (86.1%) 70 (13.9%)

History of arthritis/arthrosis

Yes 115 (77.7%) 33 (22.3%) 0.020

No 404 (85.8%) 67 (14.2%)

History of osteoporosis

Yes 63 (68.5%) 29 (31.5%) <0.001

No 456 (86.7%) 70 (13.3%)

Physical activity

Yes 174 (94.1%) 11 (5.9%) <0.001

No 345 (79.5%) 89 (20.5%)

Chi-square for Pearson: Age: a = b; a, b< c. Education: d>e> f. Self-reported of

health g<h< i. Number of physician visits j = l; j, l<m.

C.M. Nascimento et al. / Archives of Gerontology and Geriatrics 54 (2012) e89–e94e92

in older women (Fielder and Peres, 2008) in men (Grundy andGlaser, 2000) and others found no gender difference (Murtagh andHubert, 2004; Giacomin et al., 2008). Some hypotheses for thehigher prevalence of inadequate functional ability in females arerelated to the fact that women have greater longevity compared tomen (Stuck et al., 1999) and higher prevalence of disablingmorbidities (Murtagh and Hubert, 2004). Moreover, they are morelikely to report more about health conditions and disability thanmen (Murtagh and Hubert, 2004).

In this sample, the prevalence of disability increased with age inboth genders, result similar to other studies (Kawamoto et al.,2004; Fielder and Peres, 2008; WHO, 2011). Age equal or older than80 years was independently associated with inadequate functionalability as evidenced other national and international studies (Stucket al., 1999; Grundy and Glaser, 2000; Fielder and Peres, 2008). Inthis sense, physical-organic limitations can be observed in someelderly, and these in turn influence cognitive, physical, intellectualand social functioning. These changes may compromise functionalability, especially in the elderly (Maciel and Guerra, 2008).Inadequate functional ability should not be an expected phenom-enon with increasing age, and efforts should be made to avoid thislimitation in the oldest elderly.

Low monthly income was independently associated withinadequate functional ability. Other reports in the national andinternational literature show that lowest socioeconomic status isassociated with inadequate functional ability (Beydoun andPopkin, 2005; Santos et al., 2007). In general, older people withbetter socioeconomic status have better access to prevention,treatment and rehabilitation. This result is extremely important inBrazil, where inequities in healthy are still a great challenge toPublic Health.

Self-perceived health condition has been frequently used inepidemiological studies, since it is a robust indicator of mortalityand functional decline (Idler and Benyamini, 1997). In this study,we observed a significant association between disability andpoorer self-rated health, confirming results of other nationalstudies (Santos et al., 2007; Parahyba and Veras, 2008). Stuck et al.(1999) and Rodrigues et al. (2009), in a systematic review, foundthat the decline in functional ability is associated with poorerhealth condition.

The significant association observed between inadequatefunctional ability and history of hospitalization is similar to thatobserved in a study in a large Brazilian city (Rose et al., 2008). Byitself, the hospital does not seem to be a risk for disability, but theoccurrence and severity of morbidities that lead to great need forhospital care which in turn lead to functional capacity inadequate.The recovery after hospital discharge is variable, since depends on

the age and type of morbidity leading to disability, In addition, theelderly often depends on care to win disability (Covinsky et al.,2003). Covinsky et al. (2003) in a prospective study with elderly intwo U.S. hospitals found that age was associated with decliningfunctional status during hospitalization in those patients who hadnot present functional decline before hospitalization. Often thefunctional ability worsens during hospitalization, being age anindependent risk factor for the decline of functional ability in thisperiod. It is possible that the process that occurs during

Page 5: Factors associated with functional ability in Brazilian elderly

Table 3Final results of multivariate analysis of factors associated with inadequate

functional ability among elderly residents in Vicosa, Minas Gerais state, Brazil,

2009.

Variables Inadequate functional ability

RP (CI 95%)

Age (years)

60–69 1.0

70–79 1.3 (0.8–2.1)

�80 2.6 (1.4–3.7)

Monthly income (quartile) per elderly

1st (U$ 0–251.93) 1.0

2nd (U$ 251.94–283.08) 2.1 (1.0–4.6)

3rd (U$ 283.09–797.79) 1.6 (0.8–3.2)

4th (>U$ 797.80) 0.8 (0.4–1.8)

Self-reported of health

Very good/good 1.0

Fair 2.6 (1.3–5.1)

Poor/very poor 7.8 (3.9–15.8)

Number of hospitalizations in the last 12 months

None 1.0

One or more 1.7 (1.2–2.5)

Number of medications consumed in the last 15 days

Until 4 1.0

5 or more 1.7 (1.1–2.7)

History of depression

No 1.0

Yes 1.5 (1.0–2.3)

History of osteoporosis

No 1.0

Yes 1.7 (1.1–2.5)

Physical activity

No 1.0

Yes 0.5 (0.3–0.9)

C.M. Nascimento et al. / Archives of Gerontology and Geriatrics 54 (2012) e89–e94 e93

hospitalization is more harmful to older patients, and theconsequences can extrapolate the hospital environment.

The use of a greater number of medications was alsoindependently associated with inadequate functional ability. Taset al. (2007) when assessing the elderly in Rotterdam, theNetherlands, found an association between the use of more thantwo drugs and disability. This association is worrying, given thatpolypharmacy may reflect other factors besides the presence andseverity of comorbidities, such as the probability of iatrogenic, theuse of inappropriate drugs, or even the underuse of appropriatedrugs needed to control diseases (Steinman et al., 2006). This factdraws attention to the important role that medications play inmaintaining health and functional ability of elderly, beingfundamental activities that promote their appropriate prescribingin the process of health care of this population.

The literature suggests that depression increases the risk offunctional disability in the elderly due, in part, to the decrease inphysical activity and in taking part on community’s activities(Dorantes-Mendoza et al., 2007; James et al., 2011). This studyfound an association between depression and low functionalability, consistent to that reported in other studies (Dorantes-Mendoza et al., 2007; Tas et al., 2007; Rodrigues et al., 2009).

In this study, osteoporosis was independently associated withfunctional ability. Osteoporosis is characterized by loss of bonemass and deterioration of the bones’ micro-architecture due to theimbalance of osteoclasts/osteoblasts turnover (repair/replace-ment). With this, elderly are more prone to bone fractures andfalls, which are also associated with increased morbidity andmortality (Ettinger, 2003). Osteoporosis is a disease more commonamong women and is often related to functional disability, and canlead to social isolation, loss of self-esteem and, consequently todepression (Srivastava and Deal, 2002), conditions that also aid the

development of disability among the elderly. This point highlightsthe importance of actions that promote effective control of chronicdiseases in the elderly, in order to minimize the occurrence ofdisabilities and improve quality of life.

Burger et al. (1998) when studying elderly men and women inHolland, noted that an increased loss of bone mass with aging inboth men and women. The disability is associated with loss of bonemass and probably also to physical inactivity. Regular physicalactivity can increase bone strength by optimizing and improvingbone’s mineral density and therefore reduce the risk of falling(Srivastava and Deal, 2002; Ettinger, 2003). These results empha-size the importance of physical activity in old age.

In this study, physical activity was a factor independentlyassociated with inadequate functional ability, so the likelihood offunctional disability was lower among the elderly who reportedphysical activity compared to those who were sedentary. Theassociation between inadequate functional ability and physicalactivity in a cross-sectional study is difficult to interpret in view ofthe impossibility of establishing a temporal relationship. Balzi et al.(2010), in Italy, in a longitudinal study, found that both men andwomen with lower levels of physical activity had a higher risk ofdeveloping functional disability. It has been demonstrated yet thatindividuals who increase their physical activity have reducedlevels of oxidative stress and biomarkers of inflammation that mayprevent or delay development of chronic diseases. In addition,physical activity, often promotes social interaction, avoidspsychological isolation and, in turn, can prevent anxiety anddepression. All these mechanisms may contribute to the preven-tion of disability (Katz et al., 1963).

Some considerations should be noted. The first concerns the factthat there is no single method for assessing functional ability.Therefore, comparison between this study’s results and othersshould be done with caution and consideration of methodologicalapproaches. This occurs because there are different instruments,different cutoff points, different statistical analysis and no singlestandard for evaluating functional ability. It is evident, for example,that many studies use logistic regression to assess the independentassociation between characteristics of interest and functionalability. In cross-sectional studies, the odds ratio may overestimatethe magnitude of non-null findings, when the outcome is not rare,as occurs with functional disability. Suitable alternatives tocircumvent this limitation include the use of Poisson regressionwith robust variance, which was adopted in this study.

Another important consideration is the criteria adopted forclassification of functional ability of the elderly. Of the total of 14activities evaluated, 9 of them could have the answer ‘‘notapplicable’’ (as to ‘‘launder’’, ‘‘clean house’’) so that one could thinkof any classification bias due to some elderly patients with response‘‘not applicable’’ had been classified as presenting adequatefunctional ability. However, we found that for each category offunctional ability (adequate or inadequate), the percentage ofresponses ‘‘not applicable’’ did not show significant differences,except for two variables related to household chores: clean thehouse (43.3% and 32.0%) and washing and ironing (46.2% and 36.0%),respectively, for adequate and inadequate functional ability. Thus,we believe that this fact did not affect differentially the classificationof the elderly. In the case of a classification error had occurred, thiswas in the sense of increasing the proportion of elderly classified asadequate functional ability, which would have the effect of areduction in the strength of these associations. However, theconsistency of the results found in this study with the literatureshows that the final model is adequate to explain the event studied.

The combination of population to obtain the study’s samplemay be a limitation of the study, in a way of being questionedabout the possibility of selection bias. However, the similarityobserved among the elderly population of Vicosa’s municipality

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C.M. Nascimento et al. / Archives of Gerontology and Geriatrics 54 (2012) e89–e94e94

and the sample selected on the distribution by gender and agesuggests a good representative sample. Nevertheless, due to theunavailability of other characteristics of the elderly population ofVicosa, extrapolation of our results should be done with caution.

A possible limitation of this work is its cross-sectional design,which does not allow evaluation of the effect of time on theindependent variables and functional ability. This type ofrelationship can be best established in longitudinal studies.

In this work, age 80 years or older, low monthly income, self-perception of health condition as being fair and poor/very poor,history of hospitalization, polypharmacy, history of depressionand osteoporosis and physical inactivity were independentlyassociated with inadequate functional ability. Our results showedthat the factors associated with the inadequate functional abilitywere similar to those observed in the elderly in higher incomecountries and in big cities of Brazil. Given this scenario, healthprograms and actions aimed specific at this population groupshould be developed to prevent disability. Adequate control ofchronic diseases and encouragement of physical activity maycontribute to improved quality of life and healthy aging. It is alsoimportant to establish preventive measures through socialactivities to facilitate and promote formation of groups of elderlypeople, stimulating social interaction through cultural and leisureactivities. Additionally, social actions are needed to connect theelderly with health professionals through lectures and educa-tional dynamics reinforcing the importance of prevention offunctional inability and control of its associated factors.

Contributors

C.M. Nascimento collaborated in conception and design of thestudy, acquisition of data, analysis and interpretation of data,drafting the article or revising it critically for important intellectualcontent. A.Q. Ribeiro collaborated in the conception and design ofthe study, analysis and interpretation of data, drafting the article orrevising it critically for important intellectual content, finalapproval of the version to be submitted. R.M.M. Cotta collaboratedin drafting the article or revising it critically for importantintellectual content, final approval of the version to be submitted.F.A. Acurcio collaborated in final approval of the version to besubmitted. S.V. Peixoto collaborated in final approval of the versionto be submitted. S.E. Priore collaborated in drafting the article orrevising it critically for important intellectual content and finalapproval of the version to be submitted. S.C.C. Franceschinicollaborated in the conception and design of the study, drafting thearticle or revising it critically for important intellectual content,final approval of the version to be submitted.

Role of the funding source

The National Council of Research and Development – CNPq(579255/2008-5 and 474689-2008-5 process) and the Coordina-tion of Improvement of Higher Education Personnel – CAPES(23038.039412/2008-73 process) by the scholarship study andfunding of this project.

Conflict of interest statement

None declared.

Acknowledgements

We thank Jeannette Y. Wick for careful reading of ourmanuscript and relevant and helpful comments.

References

Balzi, D., Lauretani, F., Barchielli, A., Ferrucci, L., Bandinelli, S., Buiatti, E., 2010. Riskfactors for disability in older persons over 3-year follow-up. Age Ageing 39, 92–98.

Beydoun, M.A., Popkin, B.M., 2005. The impact of socio-economic factors onfunctional status decline among community-dwelling older adults in China.Soc. Sci. Med. 60, 2045–2057.

Covinsky, K.E., Palmer, R.M., Fortinsky, R.H., Counsell, S.R., Stewart, A.L., Kresevic, D.,Burant, C.J., Landefeld, C.S., 2003. Loss of Independence in activities of dailyliving in older adults hospitalized with medical illnesses: increased vulnerabil-ity with age. J. Am. Geriatr. Soc. 51, 451–458.

DATASUS, 2011. Available at http://www.datasus.gov.br (accessed on June 10).Dorantes-Mendoza, G., Avila-Funes, J.A., Mejıa-Arango, S., Gutierrez-Robledo, L.M.,

2007. Factores asociados con la dependencia funcional en los adultos mayores:un analisis secundario del Estudio Nacional sobre Salud y Envejecimiento enMexico, 2001. Pan. Am. J. Public Health 22, 1–11.

Ettinger, M.P., 2003. Aging bone and osteoporosis strategies for preventing fracturesin the elderly. Arch. Intern. Med. 163, 2237–2246.

Fielder, M.M., Peres, K.G., 2008. Capacidade funcional e fatores associados em idososdo Sul do Brasil: um estudo de base populacional. Cad. Saude Publica 24, 409–415.

Giacomin, K.C., Peixoto, S.V., Uchoa, E., Lima-Costa, M.F., 2008. Estudo de basepopulacional dos fatores associados a incapacidade funcional entre idosos naRegiao Metropolitana de Belo Horizonte, Minas Gerais, Brasil. Cad. SaudePublica 24, 1260–1270.

Grundy, E., Glaser, K., 2000. The impact of chronic multimorbidity and disability onfunctional decline and survival in elderly persons. A community-based, longi-tudinal study. Age Ageing 29, 149–157.

Idler, E.L., Benyamini, Y., 1997. Self-rated health and mortality: a review of twenty-seven community studies. J. Health Soc. Behav. 38, 21–37.

James, B.D., Boyle, P.A., Buchman, A.S., Bennett, D.A., 2011. Relation of late-life socialactivity with incident disability among community-dwelling older adults. J.Gerontol. A: Biol. Sci. Med. Sci. 66, 467–473.

Katz, S., Ford, A.B., Moskowitz, R.W., Jackson, B.A., Jaffe, M.W., 1963. Studies ofillness in the aged. The index of ADL: a standardized measure of biological andpsychosocial function. J. Am. Med. Assoc. 185, 914–919.

Kawamoto, R., Yoshida, O., Oka, Y., 2004. Factores related to functional capacity incommunity-dwelling elderly. Geriatr. Gerontol. Int. 4, 105–110.

Landi, F., Liperoti, R., Russo, A., Capuluongo, E., Barillaro, C., Pahor, M., Bernabei, R.,Onder, G., 2010. Disability, more than multimorbidity, was predictive of mor-tality among older persons aged 80 years and older. J. Clin. Epidemiol. 63, 752–759.

Lawton, M.P., Brody, E.M., 1969. Assessment of older people: self-maintaining andinstrumental activities of daily living. Gerontologist 9, 179–186.

Maciel, A.C.C., Guerra, R.O., 2008. Limitacao funcional e sobrevida em idosos decomunidade. Rev. Assoc. Med. Bras. 54, 347–352.

Murtagh, K.N., Hubert, H.B., 2004. Gender differences in physical disability amongan elderly cohort. Am. J. Public Health 94, 1406–1411.

Parahyba, M.I., Veras, R., 2008. Diferenciais sociodemograficos no declınio funcionalem mobilidade fısica entre os idosos no Brasil. Cienc. Saude Coletiva 13, 1257–1264.

Picavet, H.S., Van Den Bos, G.A.M., 1997. The contribution of six chronic conditionsto the total burden of mobility disability in the Dutch population. Am. J. PublicHealth 87, 1680–1682.

Rodrigues, M.A.P., Facchini, L.A., Thume, E., Maia, F., 2009. Gender and incidence offunctional disability in the elderly: a systematic review. Cad. Saude Publica 3,464–476.

Rosa, T.E.C., Benıcio, M.H.A., Latorre, M.R.D.O., Ramos, L.R., 2003. Fatoresdeterminantes da capacidade funcional entre idosos. Rev. Saude Publica 37,40–48.

Rose, A.M.C., Hennis, A.J., Hambleton, I.R., 2008. Sex and the city: differences indisease- and disability-free life years, and active community participation ofelderly men and women in 7 cities in Latin America and the Caribbean. BMCPublic Health 8, 127–138.

Santos, K.A., Koszuoski, R., Dias-da-Costa, J.S., Pattussi, M.P., 2007. Fatores associa-dos com a incapacidade funcional em idosos do Municıpio de Guatambu, SantaCatarina, Brasil. Cad. Saude Publica 23, 2781–2788.

Srivastava, M., Deal, C., 2002. Osteoporosis in elderly: prevention and treatment.Clin. Geriatr. Med. 18, 529–555.

Steinman, M.A., Landefeld, C.S., Rosenthal, G.E., Berthenthal, D., Sen, S., Kaboli, P.J.,2006. Polypharmacy and prescribing quality in older people. J. Am. Geriatr. Soc.54, 1516–1523.

Stuck, A.E., Walthert, J.M., Nikolaus, T., Bula, C.J., Hohmann, C., Beck, J.C., 1999. Riskfactors for functional status decline in community-living elderly people: asystematic literature review. Soc. Sci. Med. 48, 445–469.

Tas, U., Verhagen, A.P., Biema-Zeinstra, S.M.A., Hofman, A., Odding, E., Pols, H.A.P.,2007. Incidence and risk factors of disability in the elderly: The RotterdamStudy. Prev. Med. 44, 272–278.

World Health Organization (WHO), 2002. Towards a Common Language for Func-tioning, Disability and Health. ICF, Geneva.

World Health Organization (WHO), 2011. World Report on Disability. ICF,Geneva.