Biomedical subjects

Thomas M Gill

Publications and source records attributed to Thomas M Gill.

At least 37 records · Page 2Linked to original sources

PubMed2005

Underutilization of environmental adaptations for bathing in community-living older persons.

OBJECTIVES: To determine the prevalence and utilization of environmental adaptations (home modifications and assistive devices) for bathing in community-living older persons with and without bathing disability. DESIGN: Cross-sectional study. SETTING: General community of greater New Haven, Connecticut. PARTICIPANTS: Five hundred sixty-six community-living persons aged 73 and older. MEASUREMENTS: Trained research nurses performed a comprehensive assessment of bathing function, including an in-home evaluation of the bathing environment and self-reported utilization of environmental adaptations for bathing. RESULTS: The prevalence of most environmental adaptations for bathing was less than 50% and was only modestly greater in participants with bathing disability (range 6-54%) than in those without bathing disability (2-44%), although important differences in prevalence and utilization were observed according to the type of bathing disability. Participants who had difficulty (without dependence) with bathing were significantly less likely to have most of the environmental adaptations than participants who needed personal assistance (dependence) with bathing. These differences persisted in analyses that specifically evaluated the utilization of environmental adaptations for bathing transfers according to the type of disability with bathing transfers (59% of those with difficulty vs 88% of those with dependence, P<.001). CONCLUSION: Potentially valuable environmental adaptations are absent from the homes of many older persons with bathing disability and may be particularly underused by older persons reporting difficulty with bathing. To ameliorate or delay the progression of disability in community-living older persons, assessment and remediation strategies should be better targeted to bathing function across the continuum of disability.

Activities of Daily Living↗

PubMed2005

Experimental designs for multicomponent interventions among persons with multifactorial geriatric syndromes.

This paper discusses issues about the design of clinical trials to test multicomponent interventions for multifactorial health conditions, such as geriatric syndromes in which more than one risk factor is related to the outcome. The issues covered include: identification and selection of modifiable risk factors related to the outcome of interest, selection of intervention components to reduce the deleterious effects of the modifiable risk factors, assignment of components of the intervention, blinding, sample size requirements and estimation of component effects. Each of these issues is explored using examples from nine illustrative multicomponent intervention trials. Statistical and clinical concerns regarding the design of multicomponent interventions are addressed. We also propose elements of multicomponent interventions for multifactorial health conditions that should be reported in publications and areas where future research is needed.

Accidental Falls↗

PubMed2004

Hospitalization, restricted activity, and the development of disability among older persons.

CONTEXT: Preventing the development of disability in activities of daily living is an important goal in older adults, yet relatively little is known about the disabling process. OBJECTIVES: To evaluate the relationship between 2 types of intervening events (hospitalization and restricted activity) and the development of disability and to determine whether this relationship is modified by the presence of physical frailty. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study, conducted in the general community in greater New Haven, Conn, from March 1998 to March 2003, of 754 persons aged 70 years or older, who were not disabled (ie, required no personal assistance) in 4 essential activities of daily living: bathing, dressing, walking inside the house, and transferring from a chair. Participants were categorized into 2 groups according to the presence of physical frailty (defined on the basis of slow gait speed) and were followed up with monthly telephone interviews for up to 5 years to ascertain exposure to intervening events and determine the occurrence of disability. MAIN OUTCOME MEASURE: Disability, defined as the need for personal assistance in bathing, dressing, walking inside the house, or transferring from a chair. RESULTS: During the 5-year follow-up period, disability developed among 417 (55.3%) participants, 372 (49.3%) were hospitalized and 600 (79.6%) had at least 1 episode of restricted activity. The multivariable hazard ratios for the development of disability were 61.8 (95% confidence interval [CI], 49.0-78.0) within a month of hospitalization and 5.54 (95% CI, 4.27-7.19) within a month of restricted activity. Strong associations were observed for participants who were physically frail and those who were not physically frail. Hospital admissions for falls were most likely to lead to disability. Intervening events occurring more than a month prior to disability onset were not associated with the development of disability. The population-attributable fractions associated with new exposure to hospitalization and restricted activity, respectively, were 0.48 and 0.19; 0.40 and 0.20, respectively, for frail participants and 0.61 and 0.16, respectively, for nonfrail participants. CONCLUSIONS: Illnesses and injuries leading to either hospitalization or restricted activity represent important sources of disability for older persons living in the community, regardless of the presence of physical frailty. These intervening events may be suitable targets for the prevention of disability.

Activities of Daily Living↗

PubMed2004

The development of insidious disability in activities of daily living among community-living older persons.

PURPOSE: To determine how often disability in essential activities of daily living develops insidiously, and to evaluate whether the likelihood of insidious disability differs on the basis of physical frailty. METHODS: We conducted a prospective study of 754 nondisabled, community-living persons aged 70 years or older. Participants were categorized according to the presence or absence of physical frailty, which was defined on the basis of gait speed. Participants were subsequently followed with monthly telephone interviews for 3 years to determine the occurrence of disability in bathing, dressing, walking, or transferring, and to ascertain exposure to precipitating events, which included acute hospital admissions and other illnesses, injuries, or problems leading to restricted activity. RESULTS: For first episodes of disability, 73 (36%) of 203 developed insidiously among the 322 participants who were physically frail and 26 (18%) of 141 developed insidiously among the 432 participants who were not physically frail (P <0.001). Physical frailty was the only factor that was associated significantly with the development of insidious disability, with an adjusted odds ratio of 2.4 (95% confidence interval: 1.4 to 4.1). The likelihood that an episode of disability was insidious increased progressively, from 29% of the 344 first episodes to 65% of the 155 fourth or higher episodes (P for trend <0.001). CONCLUSION: Disability in essential activities of daily living often occurs insidiously, particularly among older persons who are physically frail or who have had prior episodes of disability.

Activities of Daily Living↗

PubMed2004

Recovery from disability among community-dwelling older persons.

CONTEXT: Previous studies have found that a sizeable minority of newly disabled older persons recover independent function; however, long intervals between assessments have led to difficulty in determining the true incidence and duration of disability, and therefore in accurately characterizing the probability and course of recovery. OBJECTIVES: To determine the rate of and time to recovery of independent function in community-dwelling older persons who become newly disabled in their activities of daily living (ADLs), to determine the duration of recovery, and to compare the likelihood of recovery among pertinent subgroups of older persons. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study, with monthly assessments of ADL function, for 754 initially nondisabled, community-dwelling persons aged 70 years or older, performed in a small urban area from March 1998 to May 2003. MAIN OUTCOME MEASURES: Demographic features, chronic conditions, cognitive function, and physical frailty were determined during comprehensive assessments at 18-month intervals. Disability, defined as needing personal assistance with 1 or more key ADLs (bathing, dressing, walking, and transferring), was assessed during monthly telephone interviews. RESULTS: A total of 420 participants (56%) experienced disability during a median follow-up of 51 months. Of these participants, 399 (81%) recovered (ie, regained independence in all 4 ADLs) within 12 months of their initial disability episode, and a majority (57%) of these maintained independence for at least 6 months. Among participants who experienced 3 or more consecutive months of disability, a majority (60%) recovered, but only a third of these maintained independence for at least 6 months. Persons who were cognitively impaired, physically frail, or severely disabled (ie, in 3-4 ADLs) at onset were less likely to recover than those who were cognitively intact, nonfrail, or mildly disabled, respectively. Nonetheless, a majority of participants within each subgroup recovered. CONCLUSIONS: Newly disabled older persons recover independent ADL function at rates far exceeding those that have been previously reported. Recovery from disability, however, is often short-lasting, suggesting that additional efforts are warranted to maintain independence in this high-risk group.

Activities of Daily Living↗

PubMed2004

A prehabilitation program for the prevention of functional decline: effect on higher-level physical function.

OBJECTIVE: To determine whether a home-based physical therapy (PT) program prevented decline in several higher-level measures of physical function among physically frail, community-living older persons. DESIGN: Randomized controlled trial. SETTING: General community. PARTICIPANTS: Persons (N=188) who were physically frail and aged 75 years or older. INTERVENTION: A home-based PT program (ie, prehabilitation) that focused primarily on improving underlying impairments in physical capabilities. MAIN OUTCOME MEASURES: Self-reported instrumental activities of daily living (IADLs); mobility, as determined by a modified version of the Performance Oriented Mobility Assessment; timed rapid gait and timed chair stands; and integrated physical performance, as determined by a modified version of the Physical Performance Test, were assessed at baseline, 7 months, and 12 months. RESULTS: As compared with participants in the educational control group, participants in the intervention group had reductions in IADL disability of 17.7% at 7 months (P=.036) and 12.0% at 12 months (P=.143) and had gains, ranging from 7.2% to 15.6%, in mobility and integrated physical performance at 7 and 12 months. CONCLUSIONS: Our home-based prehabilitation program offered modest but consistent benefits for the prevention of decline in several higher-level measures of physical function.

Activities of Daily Living↗

PubMed2004

The deleterious effects of bed rest among community-living older persons.

BACKGROUND: Older persons often "take to bed" while they are ill or injured, but relatively little is known about the functional consequences of bed rest among community-living older persons. In this prospective cohort study, the association between episodes of bed rest and functional decline was evaluated during an 18-month period. METHODS: Participants included 680 nondisabled, community-living persons aged 70 years or older. They were separated into 2 groups according to the presence or absence of physical frailty, which was defined based on slow gait speed. Episodes of bed rest were ascertained each month in a telephone interview for a median of 18 months. The completion rate was 99.1%. Functional decline was defined as a worsening in scores between the baseline and 18-month follow-up assessments in 1 or more of the following measures: instrumental activities of daily living, mobility, physical activity, and social activity. RESULTS: Among the 404 (59.4%) participants who had at least 1 episode of bed rest, the mean number of months with bed rest was 2.8 (standard deviation, 2.4). After adjustments were made for several potential confounders, the number of months with bed rest was significantly associated with decline in each of the functional measures. Significant associations were also observed for each of the functional outcomes among participants who were not physically frail, but they were observed only for instrumental activities of daily living disability among participants who were physically frail. CONCLUSIONS: These findings indicate that episodes of bed rest among community-living older persons are associated with decline in several important indicators of function.

Activities of Daily Living↗

PubMed2004

Getting funded. Career development awards for aspiring clinical investigators.

For aspiring clinical investigators, career development awards provide a primary mechanism for "getting funded." The objective of this article is to provide information that will facilitate a successful application for a research career development award. Specifically, we discuss important issues that cut across the diverse array of awards, and we highlight the most common sources of funding, including the unique opportunities that are available for underrepresented minorities. The target audience includes junior faculty and fellows who are pursuing or considering a research career in academic medicine, as well as their mentors and program directors.

Awards and Prizes↗

PubMed2004

Resilience of community-dwelling older persons.

OBJECTIVES: To assess resilience of community-dwelling older persons using a new scale based on response to a stressful life event and to identify the demographic, clinical, functional, and psychosocial factors associated with high resilience. DESIGN: Cross-sectional study. SETTING: Community. PARTICIPANTS: Five hundred forty-six nondisabled persons aged 70 and older who had experienced a stressful life event. MEASUREMENTS: Resilience (as assessed using a simple six-item scale), demographic factors, chronic conditions, medications, cognitive status, grip strength, functional status, physical activity, self-efficacy, depressive symptoms, self-rated health, and social support. RESULTS: Participants showed a wide range of resilience in response to a stressful event, with a mean score+/-standard deviation of 8.9+/-4.0 on an 18-point scale. In bivariate analyses, male sex, living with others, high grip strength, independence in instrumental activities of daily living (IADLs), having few depressive symptoms, and having good to excellent self-rated health were associated with high resilience, defined as a score in the best tertile (>10). Independence in IADLs (relative risk (RR)=1.36, 95% confidence interval (CI)=1.05-1.69), having few depressive symptoms (RR=1.59, 95% CI=1.13-2.11), and good to excellent self-rated health (RR=1.38, 95% CI=1.01-1.79) remained independently associated with high resilience in multivariate analysis. Depressive symptoms and self-rated health remained associated with high resilience after controlling for the perceived stressfulness of the event. CONCLUSION: Functional and psychosocial factors are associated with high resilience. Further research is needed to determine the relationship between resilience and future well-being.

Activities of Daily Living↗

PubMed2004

Bathing disability in community-living older persons: common, consequential, and complex.

OBJECTIVES: To identify the specific bathing subtasks that are affected in community-living-older persons with bathing disability and to determine the self-reported reasons for bathing disability. DESIGN: Cross-sectional study. SETTING: General community of greater New Haven, Connecticut. PARTICIPANTS: A total of 626 community-living persons, aged 73 and older, who completed a comprehensive assessment, including a detailed evaluation of bathing disability. MEASUREMENTS: Trained research nurses assessed bathing disability (defined as requiring personal assistance or having difficulty washing and drying the whole body), the specific bathing subtasks that were affected, and the main reasons (up to three) for bathing disability. RESULTS: Disability in bathing was present in 195 (31%) participants; of these, 97 required personal assistance (i.e., dependence), and 98 had difficulty bathing. Participants with bathing disability reported a mean+/-standard deviation of 4.0+/-2.4 affected subtasks. The prevalence rate of disability for the eight prespecified bathing subtasks ranged from 25% for taking off clothes to 75% for leaving the bathing position. The majority of participants (59%) provided more than one reason for bathing disability. The most common reasons cited by participants for their bathing disability were balance problems (28%), arthritic complaints (26%), and fall or fear of falling (23%). CONCLUSION: For community-living older persons, disability in bathing is common, involves multiple subtasks, and is attributable to an array of physical and psychological problems. Preventive and restorative interventions for bathing disability will need to account for the inherent complexity of this essential activity of daily living.

Activities of Daily Living↗

PubMed2004

Image of aging scale.

The development of the Image of Aging Scale is described. It ineludes positive and negative images of elders within nine domains. The scale showed good 1-wk. test-retest reliability, internal consistency, and convergent validity.

Aged↗

PubMed2003

Prognostic effect of prior disability episodes among nondisabled community-living older persons.

The objective of this prospective cohort study, conducted in 1998-2002 in New Haven, Connecticut, was to determine the prognostic effect of prior episodes of disability. The analytical sample included 580 community-living persons aged 71 years or older who were nondisabled during an 18-month face-to-face assessment (i.e., zero-time). During monthly telephone interviews, participants were assessed for disability in activities of daily living. The primary explanatory variable was a history of disability in the year prior to zero-time as determined from the monthly interviews. The primary outcome was time to onset of disability over a 3-year period subsequent to zero-time. In Cox proportional hazards analyses that adjusted for several potential confounders, a prior history of disability was found to be significantly associated with development of any disability (i.e., > or = 1 month) and persistent disability (i.e., > or = 2 months); hazard ratios were 2.0 (95% confidence interval: 1.4, 2.7) and 2.0 (95% confidence interval: 1.3, 2.9), respectively. These strong associations were maintained after participants who had a prior history of chronic disability were excluded. Results demonstrate the long-term, deleterious effect of short-term disability among community-living older persons. More frequent assessments of functional status may be warranted in epidemiologic studies and clinical trials when disability is a primary focus.

Activities of Daily Living↗

PubMed2003

Restricted activity and functional decline among community-living older persons.

BACKGROUND: Restricted activity is common among community-living older persons, but its prognostic significance is not known. We performed a prospective cohort study to evaluate the association between the occurrence of restricted activity and functional decline over an 18-month period. METHODS: We studied 680 community-living persons, 70 years or older, who were categorized into 3 groups according to their risk for disability (low, intermediate, or high) in activities of daily living (ADL). Participants were subsequently followed up with monthly telephone interviews to ascertain the occurrence of restricted activity, defined as having stayed in bed for at least half a day and/or having cut down on their usual activities due to an illness, injury, or other problem in the past month. Functional decline was defined as an increase in ADL disability scores between the baseline and 18-month follow-up assessments, which were completed in the home. RESULTS: After adjusting for the baseline risk of disability and other covariates, the disability score at 18 months increased (ie, worsened) by 11.2% (95% confidence interval [CI], 7.0%-15.6%) for each additional month with restricted activity. The association between restricted activity and functional decline differed significantly by risk group (P<.001). For the low- and intermediate-risk groups, the adjusted disability scores increased by 18.7% (95% CI, 10.3%-27.8%) and 7.5% (95% CI, 2.7%-12.5%), respectively, for each additional month with restricted activity. There was no association between restricted activity and functional decline in the high-risk group, as evidenced by a nonsignificant increase in the adjusted disability score of 2.7% (95% CI, -6.6% to 12.9%). CONCLUSION: For older persons who are not otherwise at high risk for ADL disability, restricted activity is an important predictor of functional decline and not just a benign feature of old age.

Activities of Daily Living↗

PubMed2003

Application of negative binomial modeling for discrete outcomes: a case study in aging research.

We present a case study using the negative binomial regression model for discrete outcome data arising from a clinical trial designed to evaluate the effectiveness of a prehabilitation program in preventing functional decline among physically frail, community-living older persons. The primary outcome was a measure of disability at 7 months that had a range from 0 to 16 with a mean of 2.8 (variance of 16.4) and a median of 1. The data were right skewed with clumping at zero (i.e., 40% of subjects had no disability at 7 months). Because the variance was nearly 6 times greater than the mean, the negative binomial model provided an improved fit to the data and accounted better for overdispersion than the Poisson regression model, which assumes that the mean and variance are the same. Although correcting the variance and corresponding test statistics for overdispersion is a standard procedure in the Poisson model, the estimates of the regression parameters are inefficient because they have more sampling variability than is necessary. The negative binomial model provides an alternative approach for the analysis of discrete data where overdispersion is a problem, provided that the model is correctly specified and adequately fits the data.

Activities of Daily Living↗

PubMed2003

The relationship between psychological factors and disabling musculoskeletal pain in community-dwelling older persons.

OBJECTIVES: To determine the relationship between two psychological factors (depressive symptoms and low functional self-efficacy) and the occurrence of disabling musculoskeletal pain in community-dwelling older persons. DESIGN: A 12-month prospective cohort study. SETTING: Community-based. PARTICIPANTS: Two hundred twenty-six community-dwelling persons residing in the greater New Haven, Connecticut, region, aged 70 and older, who had a history of clinically evident musculoskeletal pain and were independent in bathing, walking, dressing, and transferring. MEASUREMENTS: Levels of depressive symptoms and functional self-efficacy were determined during a comprehensive baseline assessment along with information regarding participants' demographic, medical, and physical/cognitive status. The occurrence of disabling musculoskeletal pain, defined as staying in bed for at least one-half day or cutting down on one's usual activities due to joint or back pain, was ascertained during monthly interviews. RESULTS: The mean number of months of disabling musculoskeletal pain, adjusted for baseline covariates, increased from the lowest to the highest quartile of depressive symptoms: 1.2 (95% confidence intervals = 0.8-1.7), 1.4 (1.0-2.0), 2.0 (1.5-2.8), 2.3 (1.7-3.1), respectively, P for trend =.002. The corresponding results for functional self-efficacy were (from highest to lowest quartile) 1.4 (1.0-2.0), 1.6 (1.2-2.2), 1.6 (1.2-2.2), 2.2 (1.6-3.0), P for trend =.068. There was no interaction between depressive symptoms and functional self-efficacy. CONCLUSION: Depressive symptoms and, to a lesser extent, low functional self-efficacy were each associated with the occurrence of disabling musculoskeletal pain among community-dwelling older persons.

Activities of Daily Living↗

PubMed2003

Depressive symptoms as a risk factor for disabling back pain in community-dwelling older persons.

OBJECTIVES: To determine whether the presence of depressive symptoms is an independent risk factor for disabling back pain in community-dwelling older persons. DESIGN: Prospective cohort study with a 12-month follow-up period. SETTING: General community. PARTICIPANTS: Seven hundred forty-four members of a large health plan who were aged 70 and older and independent in bathing, walking, dressing, and transferring at baseline. MEASUREMENTS: The presence of depressive symptoms, defined as a score of 16 or greater on the Center for Epidemiologic Studies-Depression Scale, was documented during a comprehensive baseline assessment that also included information regarding participants' demographic, medical, and physical/cognitive status. The occurrence of disabling back pain was ascertained during monthly telephone interviews. RESULTS: Depressive symptoms were present in 153 (20.6%) participants at baseline. Over the 12-month follow-up period, 186 participants (25.0%) reported disabling back pain during 1 to 2 months and 91 (12.2%) during 3 or more months. After adjustment for potential confounders, the presence of depressive symptoms was independently associated with the occurrence of disabling back pain (adjusted odds ratio (AOR)=2.3 (95% confidence interval (CI)=1.2-4.4) for 1 to 2 months with disabling back pain; AOR=7.8 (95% CI=3.7-16.4) for 3 or more months with disabling back pain). CONCLUSION: The presence of depressive symptoms is a strong, independent, and highly prevalent risk factor for the occurrence of disabling back pain in community-dwelling older persons.

Activities of Daily Living↗

PubMed2003

A prehabilitation program for physically frail community-living older persons.

OBJECTIVES: To describe the development and implementation of a preventive, home-based physical therapy program (PREHAB) and to provide evidence for the safety and interrater reliability of the PREHAB protocol. DESIGN: Demonstration study. SETTING: General community. PARTICIPANTS: Ninety-four physically frail, community-living persons, aged 75 years or older, who were randomized to the PREHAB program in a clinical trial. INTERVENTIONS: The PREHAB program built on the physical therapy component of 2 previous home-based protocols. A total of 223 assessment items were linked to 28 possible interventions, including progressive balance and conditioning exercises, by using detailed algorithms and decisions rules that were automated on notebook computers. MAIN OUTCOMES MEASURES: The percentages of participants who were eligible for and who completed each intervention, the extent of progress noted in the balance and conditioning exercises, adherence to the training program, and adverse events. RESULTS: Participants who completed the PREHAB program and those who ended it prematurely received an average of 9.7 and 7.2 interventions during an average of 14.9 and 9.5 home visits, respectively. With few exceptions, the completion rate and interrater reliability for the specific interventions were high. Despite high self-reported adherence to the training program, the majority of participants did not advance beyond the initial Thera-Band level for the upper- and lower-extremity conditioning exercises, and only about a third advanced to the highest 2 levels of the balance exercises. Adverse events were no more common in the PREHAB group than in the educational control group. CONCLUSION: Our results support the feasibility and safety of the PREHAB program, but also show the special challenges and pitfalls of such a strategy when it is implemented among persons of advanced age and physical frailty.

Aged↗

PubMed2003

The burden and patterns of disability in activities of daily living among community-living older persons.

BACKGROUND: The onset of disability in activities of daily living (ADLs) is considered a sentinel event in the life of an older person, but recent evidence suggests that newly disabled elders have high rates of recovery. We performed a longitudinal study to determine the burden and patterns of ADL disability among previously nondisabled, community-living older persons. METHODS: We studied 754 community-living persons, aged 70 years or older, who were categorized into three groups according to their risk for disability (low, intermediate, high). Participants were interviewed each month for 2 years to determine the presence and severity of disability in four key ADLs: bathing, dressing, walking, or transferring. RESULTS: Among the 690 nondecedents, the rates of any disability were 17.7%, 48.7%, and 65.2%, respectively, for the low-, intermediate-, and high-risk groups. Whereas only 6.9% of nondecedents in the low-risk group had more than 1 month of disability, 38.2% and 50.6% of nondecedents in the intermediate- and high-risk groups (i.e., physically frail), respectively, had multiple months and/or episodes of disability. The patterns of disability were quite diverse, with no single pattern representing the disability experience of more than half the decedents or nondecedents in any of the risk groups. CONCLUSIONS: Disability among community-living older persons, particularly those who are physically frail, is a highly dynamic process with considerable diversity. Our results provide strong evidence to support an emerging paradigm of disability as a reversible, and often recurrent, event.

Activities of Daily Living↗