One in five people may develop new physical impairment during middle age, according to a study published online November 13 in Annals of Internal Medicine.
Although many recover, almost two fifths may experience further decline or die within 10 years of disability onset, the study found. The results run counter to common notions that physical impairment is temporary in middle age and point to the need for earlier intervention in this age group.
“[T]hese findings suggest that interventions commonly used to prevent functional decline in older adults may hold promise for adults in middle age but must be tailored to meet their unique needs,” Rebecca Brown, MD, MPH, from the San Francisco Veterans Affairs Medical Center, California, and colleagues write.
The study looked at functional impairment or difficulty performing activities of daily living (ADLs), such as bathing, dressing, getting out of bed, or rising from a chair. In the elderly, functional impairment has been linked to decreased quality of life, nursing home admission, and death. Research in older adults has suggested that a first episode of functional impairment is an important harbinger of future decline.
However, many middle-aged people also experience functional impairment, for whom it is often viewed as transient and related to injuries or single diseases. Not much is known about the epidemiology and clinical course of functional impairment in this age group or whether it is similar to or different from that in the elderly.
The researchers used data from the Health and Retirement Study , a nationally representative sample of nondisabled people older than age 50 years. The analysis included 6874 adults followed for up to 20 years (50% men, 80% white). Every 2 years, participants self-reported impairment in ADLs (bathing, dressing, transferring, toileting, eating), as well as impairment in instrumental ADLs (IADLS: managing money, managing medications, shopping for groceries, preparing meals, making telephone calls). Researchers defined impairment as difficulty performing at least one ADL or one IADL.
The cumulative incidence of the first episode of ADL impairment increased with age, reaching 22% (95% confidence interval [CI], 21% – 23%) by age 64 years. The most common ADL impairment was difficulty dressing, which affected 14% of participants at least once during the study.
Ten years after first reporting an impairment in ADLs, 28% (95% CI, 26% – 30%) recovered from their initial episode, and 37% (95% CI, 35% – 39%) remained stable or reported improved functioning. However, 16% (95% CI, 14% – 18%) declined further, and 19% died (95% CI, 16% – 21%).
Participants showed a similar pattern for impairment of IADLs, with a cumulative incidence of 19% (95% CI, 18% – 20%) by age 64 years. Difficulty shopping for groceries was most common, affecting 10% (95% CI, 9% – 11%).
Risk factors for functional impairment spanned several areas, including socioeconomic status, health status, and health-related behaviors. Further analysis showed that the strongest predictors of ADL impairment were low income, stroke, and arthritis.
The pattern of progression was dynamic and similar to that in the elderly, marked by periods of improvement and decline. That finding suggests that strategies for prevention of disability in the elderly may translate to younger patients, the authors write.
In a linked editorial, Thomas Gill, MD, from the Yale School of Medicine, New Haven, Connecticut, notes the rates of disability in middle age may actually be much higher than those found in this study. That is because the study did not assess two of the most common activities affected by disability: walking and housework. Also, the study only assessed disability every 2 years and may have missed shorter periods of impairment.
The similar rates of cumulative disability in ADLs and IADLs are a “bit puzzling” but could be explained by not including housework as an IADL, he writes.
More research is needed to inform interventions aimed at preventing disability in middle age, Dr Gill adds. Such studies should include a more comprehensive array of potential risk factors, shorter assessment intervals, and consideration of intervening illnesses and injuries.
Nevertheless, he concludes: “Despite the absence of any direct comparisons, the similarities highlighted in the current study suggest that many of the tenets of disability in late life should be applicable to that occurring in middle age.”
A free summary for patients can be found here.
The study was supported by the National Institute on Aging and National Center for Advancing Translational Sciences of the National Institutes of Health. The authors and Dr Gill have disclosed no relevant financial relationships.
Ann Intern Med. Published online November 13, 2017. Abstract, Editorial
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