Disability incidence and functional decline among older adults with major chronic diseases

BACKGROUND: More than 80% of elderly Americans have at least one chronic disease. While past studies have shown that hierarchical patterns of functional loss may differ by gender and institutional settings, little is known about whether such patterns differ in relation to chronic health condition. The aim of this study is to investigate the pattern of functional loss among older adults with major chronic illnesses, and to compare their onset and ordering of incident ADL disability with those of persons without such conditions. METHODS: We use a nationally representative sample of persons aged 80+ from the 1998-2014 Asset and Health Dynamics of the Oldest Old survey. The group with major noncommunicable diseases (including cardiovascular disease, cancer, chronic respiratory disease, and diabetes) comprises 3,514,052 subjects, while the comparison group comprises 1,073,263 subjects. Self-reports of having difficulty with six distinct ADLs are used to estimate disability incidence rate. Nonparametric statistical methods are used to derive median onset ages and ADL loss sequence separately for each group. RESULTS: Older adults with major chronic diseases have higher rates of incident disability across all ADL items. Estimated median onset ages of ADL disabilities for the full sample range from 91.5 to 95.6. Disability occurs earlier for chronically ill persons (onset ages 91.1-95.0) than for those in the comparison group (onset ages 93.5-98.1). Among those with major chronic diseases, the ADL loss sequence ordered by median ages of disability onset is bathing, walking, dressing, toileting, transferring and eating. The activities are also distinctly separated into an early-loss cluster and a late-loss cluster. Although the loss sequence derived for the comparison group is largely similar, disability progression for those with major chronic diseases is compressed within a shorter timeframe and the timing gaps between adjacent disabilities are smaller. CONCLUSIONS: Older Americans with major noncommunicable diseases face an earlier and steeper slope of functional decline. Chronic care delivery programs should adapt to dynamic changes in older patients' functional status. Health interventions to help patients delay disability onset and optimize functional autonomy within emerging models of chronic care should especially target early-loss activities such as bathing, dressing, and walking.