In studies of older adults, physical function and disability are usually assessed in terms of self-reported difficulty or inability to perform specific tasks of daily life across a range of functions, e.g., activities of daily living (ADLs) such as bathing, dressing, eating, and toileting (Katz et al., 1963) or instrumental activities of daily living (IADLs) such as shopping, telephone use, meal preparation, and money management (Lawton and Brody, 1969), and mobility, upper extremity function, and exercise tolerance-demanding tasks (Nagi, 1976; Rosow and Breslau, 1966). An individual's assessment of the difficulty doing a task may be affected both by self-perception and by adaptations made to compensate for, or minimize, a decline in function. For example, an individual who has installed rails and a chair in the bath because of concerns about unsteadiness may, when questioned, report no difficulty when bathing. Therefore, in studies aimed at assessing disability in the elderly, information on adaptation to disability can provide important insights into a broader spectrum of functioning than asking about difficulty alone (Fried et al., 1991).
This chapter presents data from the Women's Health and Aging Study (WHAS) describing a spectrum of functioning among moderately to severely disabled women and the adaptations they make, including changes in the manner in and frequency with which they perform certain tasks, functional limitations related to structural aspects of the housing environment, and use of walking aids. These data provide insight into the daily lives of these women and the approaches used to compensate for disability.
For selected tasks, Table 3.1 presents the proportion of women who reported that they had no difficulty, difficulty, that they were unable to do the task, or that they did not do the task. For those who did these tasks (either with or without difficulty), the proportion doing the task less often and/or differently is provided. For a subset of these tasks, the proportion receiving help is also shown. The questions on adaptation were developed in the Johns Hopkins Functional Status Laboratory (Fried et al., 1991) and adapted for the WHAS.
Table 3.1 shows that substantial percentages of women who reported having no difficulty with a task reported changes in task performance. For example, although 48 percent of participants indicated no difficulty in walking up 10 steps without resting, 37 percent of these women performed this task less often than before. Similarly, 51 percent of participants who indicated that they had no difficulty walking one-quarter of a mile, walked this distance less often. In contrast, 92 percent of women who reported difficulty walking this distance walked it less often. Participants were also asked whether they performed selected tasks differently. Fifty percent of the women reporting no difficulty with heavy housework and 46 percent of those reporting no difficulty walking up 10 steps without resting reported doing these tasks differently than they used to. Changes in method were reported at even higher rates by women reporting difficulty with these same tasks, 68 percent and 86 percent, respectively. Other tasks in which women reported no difficulty but had changed the frequency and/or method of doing the tasks include walking across a small room, carrying 10 pounds, shopping, preparing meals, and managing money.
The data in Table 3.1 clearly show that when women had difficulty with a task, a high proportion of them reported changes in the method and/or frequency of task performance; a smaller but nonetheless substantial proportion of women who did not perceive difficulty also reported change in the method and/or frequency of task performance. Such adaptation is likely a response to functional decrements made in an effort to preserve task performance. Identifying these adaptations may be useful in understanding how individuals minimize disability and maintain independence. It is notable that tasks for which women were most likely to make adaptations were those for which this population had the highest prevalence of task difficulty or inability to perform. For example, the greatest amount of modification was reported for tasks associated with the highest mobility and exercise-tolerance requirements and the highest rates of reported difficulty and inability. These tasks included heavy housework and climbing stairs.
The importance of these modifications in task performance remains to be determined. However, these results suggest additional dimensions for describing function beyond the existing conceptual frameworks used to identify the presence of disability (Institute of Medicine, 1991; Nagi, 1976; World Health Organization, 1980). These data also suggest that the prevalence of functional decrements may be greater than that ascertained by assessing only difficulty or inability to perform activities.
Table 3.2 describes housing characteristics and the need for change in the living environment as well as reductions in the use of living space because of health problems. Eighty percent of these disabled women resided in homes where at least one step up or down was necessary to enter their home. With increasing age, a smaller proportion of women resided in homes with an entry step(s). Among all women whose homes had an entry step(s), almost 11 percent reported they were unable to walk up 10 steps without the assistance of another person or special equipment. The proportion unable to climb 10 steps increased with increasing age and disability level. For women who had entry steps, 19 percent of those age 85 years and older and 34 percent of those receiving help with ADLs reported being unable to climb 10 steps without assistance.
Of the 56 percent of women in this population who lived in homes that did not have a bathroom, bedroom, and kitchen located on the same floor, nearly one-third reported needing them on the same floor. With increasing age and disability level, the proportion of women needing their bathroom, bedroom, and kitchen on the same level increased. Among those age 85 years and older who did not have a residence with a bathroom, bedroom, and kitchen on the same floor, 42 percent needed this arrangement, in contrast to 28 percent of women age 65 to 74 years. In women with ADL difficulty who received help, 57 percent did not have their bathroom, bedroom, and kitchen on the same floor, and 58 percent of these women, compared with 17 percent of the moderately disabled, needed them on the same floor.
Few women had a walk-in shower. The proportion that needed a walk-in shower was about 20 percent and did not vary with age, but was strongly related to severity of disability. Among women with ADL difficulty who received help, 45 percent who did not have a walk-in shower stated that they needed one because of a health or physical problem.
Overall, 12 percent of participants had stopped using one or more rooms in their homes because of a health or physical condition. The rates were highest in the oldest women and the most disabled. Fifteen percent of women age 85 years and older and 35 percent of women receiving help with ADLs reported that they had stopped using one or more rooms in their home. On average, women who reported reduction in use of living space due to their health no longer used 30 to 40 percent of the rooms in their homes.
Table 3.3 presents data on the use of walking aids in various environments. When walking, 37 percent of the population used a cane, 32 percent held onto another person, and 11 percent used a walker. Overall, 3 percent of participants could not walk and 11 percent sometimes used a wheelchair. The proportion of participants using each walking aide increased with both age and level of disability, independent of the environment. In addition, 41 percent of this population reported that they reached out for, or held onto, furniture or walls to assist them in walking. This is another example of a compensatory strategy. Another adaptation, reported by 50 percent of these disabled women, is the use of shopping carts for support while shopping. These data indicate that such adaptations, or compensatory strategies, are frequently used to facilitate ongoing performance of tasks such as walking in the home or shopping for personal items. They also suggest that the proportion of this disabled population that reported use of assistive devices may not include the full spectrum of individuals who need them or may have difficulty with postural stability.
The environment in which walking occurred influenced participants' choices of assistive devices or other strategies to compensate for their disabilities. Overall, canes, wheelchairs, and the assistance of another person were used less often when the respondents walked inside the home than outside. For example, 19 percent used a cane when ambulating inside while 34 percent used one when walking outside the house. Similarly, 5 and 9 percent, respectively, used a wheelchair, and 6 and 29 percent, respectively, used the assistance of another person when walking inside, compared with outside, the home. This difference likely results from the lesser demands of walking inside in a familiar environment.
Characterizing adaptations to disability expands our insight into the spectrum of functioning among disabled older women beyond what can be learned through the usual assessment of difficulty and need for help. Further delineation of the types of adaptation used by older people and the predictive importance of such compensations will define whether this dimension can lead to better understanding of risk for further functional decline and of opportunities for prevention of disability.
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