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The prevalence of diagnoses, impairments, disabilities and handicaps in a population of elderly people living in a defined geographical area: the Gospel Oak project.

Abstract

Objective: to measure the prevalence of impairments, disabilities and handicaps in a geographically-defined elderly population.

Design: cross-sectional analysis of an interview survey.

Setting: a single North London electoral ward (district).

Participants: 654 residents (74%) over the age of 65 years were interviewed from a register of 889. A random sample of 225 had additional data collected which are reported in this analysis.

Main outcome measures: point prevalence and distribution of the total number of reported diagnoses, impairments and disabilities, and distributions of the Office of Population Censuses and Surveys (OPCS) disability scale and the London Handicap Scale scores.

Results: participants had a median of three reported diagnoses and two impairments. Forty-three percent were in the least disabled OPCS disability category (i.e. below the disability threshold) and 41% were able to undertake all of 12 basic activities of daffy living without difficulty. Overall handicap scores were heavily skewed towards no health-related disadvantage, with a median score of 83 out of 100, and 37% having a score of 90 or more. All indicators showed deteriorating health with increasing age, but age-adjusted gender differences were small.

Conclusions: an elderly population's health problems were classified using a comprehensive framework, revealing high prevalences of diagnoses, impairments, disabilities and handicaps. The schema is appropriate for health care needs assessment and is a suitable basis for describing the population's health.

Keywords: aged, cross-sectional studies, disability, handicap, health status measurement, impairment

Introduction

Epidemiology is defined as the quantitative study of the occurrence, distribution, risk factors for, and control of, diseases in populations [1]. Traditionally, epidemiology has concentrated on diagnoses, although other 'outcomes' have long been recognized as equally valid. For example, `death, disease, disability, discomfort and dissatisfaction' has been suggested as providing a more comprehensive list [2]. Wade has recently referred to a `new epidemiology' for disabling neurological disease, in which this wider focus is adopted [3]. Such an approach is probably more generally required given the pattern of health problems now encountered in older people.

Data on the occurrence of disease and its consequences are required both for epidemiological research and for health needs assessment. Efforts to define the basic epidemiology of many disorders occurring in old age have been hindered by the absence of a widely-recognized, comprehensive, framework for describing the health status people with chronic disease [4]. The World Health Organisation's International Classification of Impairments, Disabilities and Handicaps (ICIDH) is a descriptive schema which could potentially meet this need. `Impairments' are abnormalities of psychological, physiological or anatomical structure or function (for example, weakness or breathlessness). `Disabilities' refer to the performance of individual tasks and activities (such as dressing or rising from a chair). `Handicap' is the disadvantage suffered by an individual as a result of ill-health compared with what is normal for someone of the same age, sex and background [5]. Each level is a conceptually different manifestation of the effects of having a disease or combination of diseases. Collectively the different levels are referred to as `disablement'.

This paper presents cross-sectional data from the third Gospel Oak survey. The first two Gospel Oak surveys obtained data on the prevalence and incidence of depression, dementia and `activity limitation' [6- 9]. The third survey aimed to repeat these estimates, to follow-up subjects on whom data had been obtained in earlier surveys and to study factors predisposing to depression using a more systematic approach to the description of the consequences of ill-health [10, 11]. We report here the prevalence of health problems in Gospel Oak in terms which are concordant with the needs of the `new epidemiology'.

Methods

Participants

The methods used have been described previously [6, 10]. The study population was defined as that resident in the Gospel Oak electoral ward and over 65 years of age, on 1 December 1993. Gospel Oak is a mixed residential area of inner North London, containing some expensive privately-owned houses, some high-quality low-rise local authority housing and several poorly maintained medium- and high-rise blocks.

A population register was compiled based on a door-to-door census during November 1993. Up to three attempts were made to identify the inhabitants of each address in the study area. Eligible subjects were then approached by letter, along with a letter of introduction from their general practitioner, to consider an interview. The register was modified following responses to these letters, from eligible subjects encountered during interview visits and from additional names obtained from the Family Health Services Authority records, the records of the Social Services Department of the London Borough of Camden and a case register maintained by the Department of Old Age Psychiatry at the Royal Free Hospital. Throughout this period, additions to the list relied on the same definition for eligibility for inclusion. Residents who moved into the area after 1 December 1993 were excluded.

Interviews and measurements

Most interviews were carried out in the homes of the participants. In a few cases residents requested that the interview be held in the hospital. The interview was based on the short Comprehensive Assessment and Referral Evaluation (CARE) schedule [12, 13]. This is a structured questionnaire, covering personal and demographic details, and scales for the diagnosis and quantification of dementia, depression and `activity limitation'. In addition, data were sought on social support, income, physical symptoms, disability and handicap. Disability was measured using the 12-item Medical Research Council-ALPHA activities of dally living (ADL) scale, adopted in the European collaborative `Eurodem' study [14]. Handicap was measured using the London Handicap Scale [15] in an interviewer-administered format.

A team of eight interviewers were recruited, all of whom had some health service background. Training in the interview schedule included the rating of a video-taped interview and the dual rating of an interview by a psychiatrist (M.P.) and the interviewer. A one in three random sample was interviewed by a geriatrician (R.H.), who added items eliciting further medical diagnoses and impairments, administered the Office of Population Censuses and Surveys (OPCS) disability scale [16] and made a subjective assessment of housing quality. Diagnoses were made and impairments recorded according to the clinical judgement of the investigator, after a brief clinical history and simple physical examination. A checklist was used for each. Prow information was recorded in cases where the participant could not answer for him or herself. A variety of assessments of housing quality were made, including tenure, type, size and facilities. These were used to validate the subjective measure.

The ADL scale was scored on the basis of `no problem with the activity'/`any problem', and the adequacy with which it formed a hierarchical scale tested with a scalogram analysis [17]. The OPCS disability scale (based on the disability section of the ICIDH), allows measurement of 13 disability dimensions (locomotion, reaching and stretching, dexterity, personal care, continence, seeing, hearing, communication, behaviour, intellectual functioning, consciousness, eating and drinking and disfigurement). Each dimension has list of tasks or activities arranged hierarchically in order of difficulty, with the final task defining a threshold beyond which no disability was deemed to exist.

Handicap is described by considering disadvantage in each of six dimensions: mobility, physical independence, occupation, social integration, orientation and economic self-sufficiency [5]. The London Handicap Scale comprises a handicap classification questionnaire covering these dimensions and a matrix of scale weights relating to responses on each of the dimensions. The scale weights were derived from valuations made by a representative external population and can be combined to give an overall interval-level handicap score. The score is an estimate of the relative desirability (`utility') of the state of health described [15, 18]. A handicap score of 100 implies no disadvantage, whilst a score of 0 represents maximum disadvantage.

Statistical analysis

A `diagnosis score' and `impairment score' were calculated by simply counting the number of diagnoses or impairments reported. The representativeness of the one in three random sample was assessed by comparing it with the whole population with respect to health and demographic variables. The proportion of subjects reporting each diagnosis, impairment, disability and handicap were calculated. The distributions of numbers of diagnoses and impairments, the ADL and OPCS disability scores and the handicap score were calculated separately for the age groups 65-74 years, 75-84 years, and over 85 years. The same data were compared for men and women after direct standardization for age in 5-year age bands, using the age distribution of the whole population as standard.

Results

The study population

From the final population register of 889 names, 654 subjects were interviewed--a response rate of 73.6%. Of those not interviewed, 51 (5.7%) died before an interview could be arranged, 127 (14.3%) refused and 54 (6.1%) could not be contacted or repeatedly deferred invitations to be interviewed.

Sixty-one percent of interviewees were female. Fifty-six percent were aged 65-74, 34% were 75-84 and 10% were 85 years or older. Most were UK-born white people (82%), with minorities from Eire (8%), Southern and Eastern Europe, Asia, the West Indies and North America. Sixty-eight percent had been involved in manual occupations (Registrar General classes IIIM, IV and V) and only 16% owned their own homes. The general standard of accommodation was, on the whole, satisfactory, although 20% thought their home to be unsuitable for them. There were no outside toilets. Almost all had central heating. Access to accommodation was by stairs for 62% of respondents, although 54% of these had the option of using a lift; 36% had indoor stairs. Overall, 53% needed to be able to climb stairs. Half lived alone. Half were reliant on the basic state pension or other benefits, but 29% had an additional income of 100 [pounds sterling] or more a month.

The random sample comprised 225 subjects, for 233 of whom complete data were available. A comparison of social and demographic features, dementia, depression, disability and handicap scores showed that differences between this sample and the population as a whole were quantitatively small and could all have arisen by chance, confirming the comparability of the populations (Table 1). In view of this and to maximize precision, results are quoted from the sample or the population as a whole, depending on availability of data.
Table 1. Adequacy of random sample interviewed by a geriatrician

                          Interviewed by
                          geriatrician   All

Variable                  n     Value    n     Value

Mean age (years)          223   75.5     654   75.4
Proportion
  Female                  223   58%      654   61%
  Living alone            223   48%      654   49%
  Currently married       223   41%      654   37%
  Manual occupation       223   70%      593   68%
  >9 years education      223   27%      654   29%
  Dementia                223   10%      585   10%
  Depression              221   19%      645   18%
Mean score
  Handicap(/100)          223   79       642   78
  ADL (failed items/12)   223    2.2     651    2.1


ADL, activities of daily living.

Diagnosis

The most frequent diagnosis was arthritis, reported by 58% of the subjects and most often affecting the knees (32%). Lumbar spondylosis was present in 20%, hand arthritis in 15%, hip arthritis in 14% and cervical spondylosis in 11%. Fifteen subjects (7%) had had a joint replacement, and seven (3%) a fractured femur. Other reported diagnoses were: heart disease (22%), diagnosed hypertension (26%), lung disease (22%), eye disease (15%), cancer (8%), stroke (5%), diabetes (5%) and other neurological disease (3%). The prevalence of `pervasive depression' from the short-CARE instrument was 17% and the prevalence of dementia was 9.8%. Only 9% of subjects had no known diagnoses, whilst 52% had three or more (Table 2).
Table 2. Distribution of number of diagnoses

                   % of patients, by group

                   Age group (years)

                   65 - 74     75 - 84    [is greater than
No. of diagnoses   (n = 125)   (n = 73)   or equal to] 85
                                              (n = 25)

0                  13%          4%             4%
1-2                44%         36%            28%
3-4                33%         38%            40%
5-6                10%         18%            20%
7+                  1%          4%             8%
Mean (median)       2.4 (2)     3.1 (3)        3.4 (3)

                   Sex (age-standardized)

                   Male       Female      Total
No. of diagnoses   (n = 93)   (n = 130)   (n = 223)

0                   6%        12%          9%
1-2                37%        41%         39%
3-4                37%        34%         35%
5-6                19%         9%         14%
7+                  1%         4%          3%
Mean (median)       2.9 (4)    2.5 (3)     2.7 (3)


Impairments

Half the sample (53%) reported pain, mostly in joints or the back; 11% also reported joint stiffness. One-quarter reported dizziness (23%), breathlessness (24%) or urinary symptoms (27%). Sixteen percent had fallen in the previous 6 months. Fourteen percent had generalized or specific weakness of the limbs. When visual and hearing impairment were assessed in the main questionnaire, 85% of subjects reported no visual impairment, 6% had minor impairment, 7% were impaired to the extent that they could only read large print and 2% were blind. Similarly, 74% reported no hearing impairment, 13% had minor hearing problems, 13% could hear a shouted voice and two subjects (0.3% of the total study population) were so deaf as to render verbal communication impossible. Twenty-one percent had no impairments of any kind and 41% suffered more than three (Table 3).
Table 3. Distribution of number of impairments

                     % of patients, by group

                     Age group (years)

                     65 - 74     75 - 84    [is greater than
No. of impairments   (n = 125)   (n = 73)   or equal to] 85
                                                (n = 25)

0                    27%         14%             8%
1-2                  44%         43%            16%
3-4                  26%         33%            36%
5-6                   3%         18%            36%
7+                    0           3%             4%
Mean (median)         1.7 (2)     2.7 (3)        3.6 (3)

                     Sex (age-standardized)

                     Male       Female      Total
No. of impairments   (n = 93)   (n = 130)   (n = 223)

0                    21%        20%         21%
1-2                  37%        36%         37%
3-4                  33%        29%         29%
5-6                   9%        12%         11%
7+                    0          2%          1%
Mean (median)         2.1 (2)    2.3 (2)     2.3 (2)


Disabilities

Disabilities were characterized in two ways: using a hierarchical ADL scale and the OPCS disability dimensions and overall disability categories. The scalogram analysis of the ADL scale revealed an adequate hierarchical scale with a coefficient of reproducibility of 0.94 and a coefficient of scalability of 0.67. (Conventionally a scale is considered to form an adequate hierarchy if the coefficient of reproducibility is [is greater than] 0.9 and the coefficient of scalability is [is greater than] 0.6 [19].)

Forty-three percent were ill the least disabled OPCS category, i.e. no reported disability (Table 4). Locomotor disability was the most prevalent, and subjects were divided into three separate categories for analysis. Sixty percent had no locomotor disability (using a threshold of being able to walk 400 m and climb a flight of stairs normally). Twenty-two percent had mild or moderate disability (at worst being able to walk 50 yards without stopping) and 18% were more severely disabled. The most prevalent disabilities after locomotion were in hearing (21%), intellect (17%), behaviour (16%), reaching and stretching (13%), personal care (13%), continence (13%), seeing (11%), dexterity (8%), communication (4%), consciousness (3%) and eating and digestion (1%). No-one had a disfigurement disability.

Table 4. Distribution of Office of Population Censuses and Surveys disability scale categories
                % of patients, by group

                Age group (years)

                65-74       75-84      [is greater than
Category        (n = 125)   (n = 73)   or equal to] 85
                                           (n = 25)

0               62%         23%                4%
1-2             19%         38%               12%
3-4              9%         12%               16%
5-6              6%         12%               32%
7-8              2%          8%               20%
9-10             2%          5%               16%
Mean (median)    1.2 (0)     2.7 (1)           5.6 (6)

                 Sex (age-standardized)

                 Male       Female     Total
Category         (n = 25)   (n = 93)   (n = 130)

0                40%        44%        43%
1-2              29%        22%        25%
3-4              11%        11%        11%
5-6              10%        11%        11%
7-8               3%         8%         6%
9-10              6%         3%         5%
Mean (median)     2.2 (1)    2.2 (1)    2.2% (1)


The proportion able to undertake all the ADL without difficulty was 41% (Table 5). In keeping with the strict definition of disability, any difficulty in performing an activity was recorded. Descending the hierarchical scale of difficulty, the proportions with disabilities in different activities were: cutting nails (51%), climbing stairs (41%), using the bath (29%), putting on shoes (20%), fastening zips (14%), dressing (12%), getting around the house (12%), getting in and out of bed (10%), using the toilet (9%), shaving or doing hair (9%), washing hands (5%) and feeding (2%).

Table 5. Distribution of hierarchical Medical Research Council-ALPHA activities of daily living (ADL) scale scores
                % of patients, by group

                Age group (years)

                65-74       75-84       [is greater than
ADL score       (n = 365)   (n = 222)   or equal to] 85
                                            (n = 67)

0               54%         29%              8%
1               16%         12%             20%
2               11%         21%             12%
3                6%         16%             12%
4-6              6%         11%             20%
7-9              4%          8%             12%
10-12            3%          3%             16%
Mean (median)    1.5 (0)     2.7 (2)         4.3 (4)

                Sex (age-standardized)

                Male        Female      Total
ADL score       (n = 258)   (n = 396)   (n = 654)

0               42%         39%         41%
1               12%         17%         15%
2               20%         11%         14%
3               12%         10%         10%
4-6              3%         12%          9%
7-9              6%          7%          6%
10-12            6%          4%          4%
Mean (median)    2.2 (1)     2.3 (1)     2.5 (1)


Handicaps

On each dimension, apart from economic self-sufficiency, about half the participants had no disadvantage. The least disadvantaged economic level described a positive advantage over what might normally be expected, and the second level (out of six) was the most prevalent. Thereafter, each of the levels on each dimension showed a sharp decline in prevalence towards the more severe disadvantages (Table 6). As might be expected in a community-dwelling population, the distribution of overall handicap scores was heavily skewed towards no disadvantage, with 37% of subjects scoring between 90 and 100, and only 10% scoring [is less than] 50 (Table 7). The median score was 83.

Table 6. Distribution of handicaps on the six dimensions of the London Handicap Scale (n = 642)
                            Level of disadvantage(a)

Dimension                   1     2     3     4     5      6

Mobility                    49%   17%   23%   11%   0.3%   0.2%
Physical independence       58%   11%   19%   10%   1%     0.3%
Occupation                  45%   18%   11%   14%   9%     3%
Social integration          54%   32%    4%    6%   4%     0.2%
Orientation                 62%   24%   10%    3%   1%     0
Economic self-sufficiency   25%   43%   13%   17%   2%     0


Table 7. Distribution of London Handicap Scale scores (higher handicap scores imply less handicap)
                 % of patients, by group

                 Age group (years)

                 65-74       75-84       [is greater than
Handicap score   (n = 365)   (n = 222)   or equal to 85
                                            (n = 67)

 0-10             0           0               0
11-20             0.3%        0               0
21-30             0           1%              6%
31-40             1%          3%             16%
41-50             3%          8%             14%
51-60             4%         15%             19%
61-70            12%         15%             20%
71-80            10%         20%              9%
81-90            20%         15%              8%
91-100           49%         25%              8%
Mean (median)    85 (90)     74 (75)         58 (57)

                 Sex (age-standardized)

                 Male        Female      Total
Handicap score   (n = 258)   (n = 396)   (n = 642)

 0-10             0           0           0
11-20             0.4%        0           0.2%
21-30             2%          0.7%        0.9%
31-40             3%          3%          3%
41-50             7%          5%          6%
51-60             5%         11%          9%
61-70            14%         15%         14%
71-80            14%         13%         13%
81-90            17%         17%         17%
91-100           37%         36%         37%
Mean (median)    77 (83)     79 (83)     78 (83)


Variation with age and sex

After standardization for age, the distributions of numbers of diagnoses and impairments, disability scores and handicap scores were very similar between men and women. For each index of ill-health, however, there was a deterioration with increasing age (Tables 2 - 5 and 7). For example, those aged 65- 74 years had a mean of 1.7 impairments, rising to 2.7 in those aged 75-84, and 3.6 in the over-85s. Correspondingly, the proportions with no diagnoses, impairments, disabilities or handicaps declined with increasing age.

Discussion

This paper presents data on the prevalence of diagnoses, impairments, disabilities and handicaps in a general population. The importance of classifying and documenting the consequences of ill-health in this way is that it provides a comprehensive picture of the health of a population, and the basis for defining health care need and evaluating the effectiveness of interventions aimed at meeting those needs.

The people of Gospel Oak have higher than average indices of deprivation than the UK population as a whole, but the population interviewed was reasonably representative of that in an urban area. The 889 names on the final population register compared with a 1991 census population of 1029, of whom 9.5% were `absent residents' or visitors, leaving 931 permanent residents. It was therefore likely that at least 95% of elderly residents had been identified. The response rate of 74% was reasonable for this type of research. Most probably subjects who died before interview could be arranged would have been more disabled and handicapped, and would have had more diagnoses and impairments. The part of the population that could not be contacted may have been elusive because of ill-health, but were equally likely to be fit people who would rather spend their time doing other things. The random sample were similar in all respects to the population (who participated) as a whole.

Diagnoses relied on self-report by the subjects, or were made after a brief clinical history taken by an experienced physician. Diagnoses are useful when considering specific curative or palliative medical therapy, in evaluating prevention programmes, in providing explanations of symptoms and in making a prognosis. Some diagnoses (such as cancer) are associated with stigma or are culturally feared, have particular prognostic significance or may give access to specific benefits or support groups. Otherwise, diagnoses per se have little direct significance for patients. The manifestations of disease in terms of impairments and disabilities are of more relevance, but are nonspecific, in that several different diagnoses may cause impairments like pain or shortness of breath and disabilities like immobility. Impairments and disabilities are phenomena which require explanation in terms of diagnoses, and palliation or rehabilitation where they cannot be alleviated by curing a disease. In the ICIDH schema, handicap is the final integrating level, in which health experience is described after taking into account the social, environmental and personal context in which it occurs. Mobility handicap, for example, is influenced by the immediate physical environment, aids, appliances and vehicles, transport policy, the availability of help, confidence and personal desires and definitions of normal life. Description at this level is needed in evaluating packages of interventions acting at different levels (such as `rehabilitation' or whole services), comparing interventions across different diseases and types of intervention, and in determining the relative contributors to overall health status in a population.

The classification does retain some ambiguity. For items such as seeing, hearing, intellect and behaviour, the differentiation between an impairment and a disability rests on the identification of `tasks' associated with these faculties. Thus intellectual `tasks' include letter writing, the use of money, understanding a newspaper article and passing on messages. Seeing tasks include recognizing a friend across the road and reading a book. Almost all the behaviour disability in this study resulted from people spending significant amounts of time doing nothing (comparable to an occupation handicap). In practice, the distinction between different levels can be difficult to sustain. Measurement of cognitive or visual impairment involves setting abstract intellectual or visual tasks. Many mobility handicaps (such as being unable to go everywhere you want or being housebound) describe `activities' set in a broader context and include what traditionally have been termed `extended' or `instrumental' ADLs. The entities of impairment, disability and handicap remain distinct, however. Visual impairment, for example, contributes to both seeing and intellectual disability, and the prevalence of intellectual disability (17%) was greater than that of formally measured cognitive impairment (9.8%).

Despite the attractions of the ICIDH as a taxonomic framework, and usage in rehabilitation practice, the population prevalences of ICIDH-defined impairments, disabilities, and handicaps have not been reported previously. A total population survey from New Zealand reported age- and sex-specific prevalences of disabilities, and then documented the diagnoses associated with them, the impairments causing dressing disabilities, and the effect of disabilities on independence (as a proxy for handicap) [20]. Other studies have documented impairments, disabilities and handicaps in specific groups, such as rehabilitation patients [21], respiratory disease [22] and preterm neonate survivors [23].

A striking feature of the results is how common individual and multiple diagnoses, impairments, disabilities and handicaps were in the population. Conversely, complete freedom from disease or the consequences of disease was relatively rare, and was increasingly so as the age of participants increased. Results were broadly in line with other available population health survey data. For example, in the 1984- 85 OPCS disability survey [ 16] the prevalences of disabilities, adjusted approximately for the age distribution in Gospel Oak, were 35% for locomotion (40% in this study), 10% for reaching and stretching (13%), 14% for dexterity (8%), 16% for seeing (11%), 22% for hearing (21%), 20% for personal care (13%), 10% for continence (13%), 9% for communication (4%) and 10% for behaviour (16%). Differences may be partially accounted for by residual confounding by age (the OPCS report only gave broad age categories) and because of under-representation of institutional residents in the Gospel Oak sample compared with the national average.

The ICIDH framework provides a viable basis for the comprehensive description of health status in a population. As expected indices of diagnosis, impairment, disability and handicap were all heavily age-dependent, making crude comparisons between populations difficult, but important in projecting future health needs as the population ages. The high prevalences reported lend support for the targeting of research on interventions for health problems in old age, and the targeting of resources on this group where effective interventions are established.

Key points

* Health problems of people over 65 living in Gospel Oak, London, were quantified in terms of diagnoses, impairments, disabilities and handicaps.

* Participants had a median of three diagnoses and two impairments.

* More than half reported some disability.

* Handicap scores were widely distributed, but were skewed towards no health-related disadvantage.

* All indicators showed deteriorating health with increasing age.

Acknowledgements

R.H. was an MRC Health Services Research Training Fellow and M.P. was a Wellcome Trust Clinical Epidemiology Training Fellow. Angela Thomas provided administrative support for the study.

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Received 21 July 1997; accepted 31 October 1997

ROWAN H. HARWOOD, MARTIN J. PRINCE(1), ANTHONY H. MANN(1), SHAH EBRAHIM

University Department of Primary Care and Population Sciences, Royal Free Hospital, London NW3 2PF, UK (1) Section of Epidemiology and General Practice, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK

Address correspondence to: R. H, Harwood, Department of Health Care of the Elderly, A Floor East Block, Queen's Medical Centre, Nottingham NG7 2UH, UK. Fax: (+44) 115 970 9947
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Author:HARWOOD, ROWAN H.; PRINCE, MARTIN J.; MANN, ANTHONY H.; EBRAHIM, SHAH
Publication:Age and Ageing
Geographic Code:4EUUK
Date:Nov 1, 1998
Words:4925
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