Prevalence and Factors Associated with Impairment of Instrumental Activities of Daily Living in Older People: A Population Study

  

    
Variables
    
ORadj
    
CI (95%)
    
Padj
  
  

    
Age group
    

    

    

  
  

    
60 |–| 69 years
    
1
    

    

  
  

    
70 |–| 79 years
    
1.72
    
1.16 – 2.57
    
0.007
  
  

    
80 years or older
    
6.54
    
3.26 – 13.14
    
<0.001
  
  

    
Marital status
    

    

    

  
  

    
Married
    
1
    

    

  
  

    
Widowed
    
1.71
    
1.07 – 2.76
    
0.025
  
  

    
Single
    
0.69
    
0.35 – 1.36
    
0.286
  
  

    
Divorced
    
0.92
    
0.48 – 1.75
    
0.8
  
  

    
Lives alone
    

    

    

  
  

    
No
    
1
    

    

  
  

    
Yes
    
0.47
    
0.26 – 0.87
    
0.017
  
  

    
Cerebrovascular accident
    

    

    

  
  

    
No
    
1
    

    

  
  

    
Yes
    
2.4
    
1.01 – 5.73
    
0.048
  
  

    
Self-rated health
    

    

    

  
  

    
Very good/Good
    
1
    

    

  
  

    
Fair
    
1.36
    
0.93 – 2.01
    
0.114
  
  

    
Poor/Very poor
    
4.56
    
1.94 – 10.73
    
0.001
  
  

    
Cognitive impairment
    

    

    

  
  

    
No
    
1
    

    

  
  

    
Yes
    
1.7
    
1.08 – 2.69
    
0.021
  
  

    
Musculoskeletal disorder
    

    

    

  
  

    
No
    
1
    

    

  
  

    
Yes
    
1.69
    
1.08 – 2.65
    
0.022
  
  

    
95% CI: 95% Confidence Interval; OR: Odds    ratio.

      Hosmer Lemeshow (p=0.080) Area under the    ROC curve (AUC=0.765).

      Adjusted for sex, diabetes, hospitalization,    hearing impairment, osteoporosis, and hypertension. 
  

Table 5: Factors associated with IADL disability, Goiânia - GO, Brazil, Dec. 2009-Apr. 2010 (n=927).

In the adjusted analysis, we identified that age older than 70 years (OR=1.72; p=0.007), or 80 years of age or older (OR=6.54; p=<0.001), widowed marital status (OR=1.71; p=0.025), having suffered a cerebrovascular accident (OR=2.40; p=0.048), poor or very poor selfrated health (OR=4.56; p=0.001), presenting cognitive impairment (OR=1.70; p=0.021), musculoskeletal disorder (OR=1.69; p=0.022), and living alone (OR=0.47; p=0.017) were factors associated with functional disability for IADL, and living alone proved to be the only protective factor. The final model was considered adequate (Hosmer- Lemeshow, p=0.508) and with a predictive capacity of 76.5%.

Discussion

The present study allowed us to evaluate the functional capacity of a representative sample of older people living in the city of Goiânia- GO, Brazil. The prevalence of IADL disability (58.2%) was higher than findings at the international level, in which the prevalence of IADL disability accounted for 8.0% and 35.75% [21-24] and was higher or similar to the results of studies performed in the national scenario, in which the prevalence of disability was between 34.2% and 78.3% [2,7,9,25,26].

This is possibly due to the use of different instruments for assessing functional capacity, or even the use of the Lawton’s scale adapted according to the reality of the studied population, excluding or adding items from the original scale [23-26]. It is worth noting that the studies were carried out in different regions, some with greater social vulnerability, showing a higher prevalence of impairment of IADL [9,25].

The high prevalence of IADL disability is a worrisome fact, since it is a factor that potentiates the risks for health problems, social isolation, institutionalization and hospitalization, and it may decline more rapidly in relation to ADL, thus increasing the older adults’ level of dependence [7-25]. Hence, the need for investigating factors associated with the condition of disability in carrying out daily activities in older people is emphasized, in order to develop policies and strategies that minimize this type of limitation.

Concerning IADL with greater impairment among older individuals, we identified doing manual work, doing the laundry, ironing, and housekeeping, which are similar to those reported by other studies [4,10,14,27]. We found no studies whose authors evaluated the item “doing manual work,” even after its inclusion by the Brazilian Ministry of Health in 2006 [17]. However, our results suggest that the inclusion of the evaluation of manual work is extremely important for the functional assessment, considering that this item was identified as the main functional impairment in IADL among the studied population. In addition, after stratification by age and sex, doing manual work was the only activity that remained statistically significant in all age groups and for both sexes.

In this study, we identified that age older than 70 years, widowed marital status, having suffered a cerebrovascular accident, poor or very poor self-rated health, having cognitive impairment, musculoskeletal disorder, and living alone were factors associated with IADL disability in the adjusted analysis.

Authors of several studies have pointed out the association between increasing age and higher frequency of functional disability for IADL [7,9,21,22,26,28], which may be related to changes inherent in the aging process that contribute to the higher frequency of this outcome. Regarding widowhood, a meta-analysis carried out by authors who sought to analyze the association between marital status and health conditions demonstrated that widowhood is a determining factor of quality of health, especially among older adults, but the way it is affected has not yet been fully understood [29]. A justification for this finding is that widowhood can lead to social isolation and depressive symptoms, thus having a negative impact on the general health condition of the older adult [30].

In our research, CVA consisted in one of the three factors strongly associated with dependence concerning IADL. Frequently, after a stroke episode, people may have physical, cognitive and behavioral sequelae, which in turn compromise the functional capacity, interfering with autonomy and independence [31]. Authors of a study conducted with data from North American civilian residents highlighted that 29.2% of CVA survivors reported needing help with IADL, whereas only 4.2% of individuals without a history of CVA needed help in relation to IADL [32].

Research involving older people living in the city of São Paulo (SP), Brazil, showed a significant association between IADL disability and poor self-rated health, which corroborates our study. It was emphasized that dependence regarding IADL causes older adults to be 5.33 times more likely to have worse self-rated health [33]. Zanesco et al. [34] obtained similar results, verifying that older people who presented some limitation for IADL were 2.04 times more likely to report a negative perception of health. Possibly, older adults perceive their negative health status due to the difficulty in independently carrying out activities that involve living in the community, noticing a compromise of their physical and cognitive integrity, thus reducing their autonomy [26,34].

Another factor associated with IADL disability in this study was to present cognitive impairment. Functional loss related to IADL is evident from milder stages of cognitive impairment. In a study carried out on older people in the North of the state of Minas Gerais, Brazil, a high prevalence of IADL impairment (78.3%) and some degree of cognitive impairment (79.2%) were observed, emphasizing that IADL require greater cognitive integrity when compared with ADL [9]. Researchers show that cognitive impairment, assessed by different scales or medical diagnosis, negatively influences the functional capacity of older adults as for IADL, whether it is mild, moderate, or severe, and in both sexes [12,35,36].

Concerning diseases, IADL disability was significantly associated with musculoskeletal disorders. According to the literature, musculoskeletal disorders interfere with the functional capacity of older people, causing pain and limiting their mobility [37-39]. Among musculoskeletal disorders, the one with the greatest relationship with functional impairment is osteoarthritis. In Turkey, this condition was found to significantly affect the ability to prepare meals, and individuals with this morbidity were 2.82 times more likely to be unable to perform this IADL, one of the difficulties that was also verified in our study [36].

All the aforementioned factors were related to IADL disability. Conversely, living alone was identified as a protective factor against functional disability for IADL. Nunes et al. [12] and Aguiar et al. [9], as well as in this study, showed that living alone was statistically associated with decreased IADL disability. These findings are probably related to the greater independence and autonomy that older people must have when living alone, which often does not occur when they are with other people, and they may even be deprived of performing more complex tasks [9,40]. On the other hand, it is important for older adults to have social and family support, in such a way to prevent the feeling of loneliness and the development of depressive symptoms [41].

Conclusion

Our results allow us to conclude that the prevalence of functional disability for IADL was 58.2%. The most compromised activities were doing manual work, doing the laundry, ironing, and housekeeping.

We also observed differences in relation to sex in the age group of 60 and 69 years for preparing meals and doing manual work. In the age group of 70 to 79 years, differences were observed as for the use of modes of transportation, preparing meals, and doing manual work. For long-lived older adults, we found associations regarding the use of modes of transportation, shopping, and doing manual work.

Factors associated with functional disability for IADL were age older than 70 years, widowed marital status, having suffered a CVA, poor or very poor self-rated health, having cognitive impairment, and musculoskeletal disorder; living alone was deemed a protective factor.

The loss of the capacity for IADL is a warning for other changes in the older adults’ functionality and, consequently, in all its outcomes such as hospitalization and loss of autonomy.

Investment in health promotion and coping strategies in all age groups aiming at promoting health and preventing injuries that compromise musculoskeletal mobility and flexibility may guarantee autonomy and independence for as long as possible. The expansion of formal and informal support networks could favor the social insertion of older adults. In this sense, the interdisciplinary and intersectoral articulation between health, transportation, education, and social assistance sectors is necessary.

Moreover, considering that capacity impairments could be affected by environmental conditions, we suggest that these factors should also be considered in future research in IADL.

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