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Heather Allore

Publications and source records attributed to Heather Allore.

11 recordsLinked to original sources

A case study found that a regression tree outperformed multiple linear regression in predicting the relationship between impairments and Social and Productive Activities scores.

OBJECTIVE: Many important physiologic and clinical predictors are continuous. Clinical investigators and epidemiologists' interest in these predictors lies, in part, in the risk they pose for adverse outcomes, which may be continuous as well. The relationship between continuous predictors and a continuous outcome may be complex and difficult to interpret. Therefore, methods to detect levels of a predictor variable that predict the outcome and determine the threshold for clinical intervention would provide a beneficial tool for clinical investigators and epidemiologists. STUDY DESIGN AND SETTING: We present a case study using regression tree methodology to predict Social and Productive Activities score at 3 years using five modifiable impairments. The predictive ability of regression tree methodology was compared with multiple linear regression using two independent data sets, one for development and one for validation. RESULTS: The regression tree approach and the multiple linear regression model provided similar fit (model deviances) on the development cohort. In the validation cohort, the deviance of the multiple linear regression model was 31% greater than the regression tree approach. CONCLUSION: Regression tree analysis developed a better model of impairments predicting Social and Productive Activities score that may be more easily applied in research settings than multiple linear regression alone.

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Estimates of active and disabled life expectancy based on different assessment intervals.

BACKGROUND: Although disability in activities of daily living (ADLs) is a highly dynamic process, analytic strategies for estimating active and disabled life expectancy have assumed stability in ADL function between periodic surveys spanning 12--24 months or have used interval estimation or instantaneous rates based on long assessment intervals. We performed a prospective cohort study to compare estimates of active and disabled life expectancy based on traditional assessment intervals of 1--2 years with those based on more frequent assessments at 1-month intervals. METHODS: Participants included 754 initially nondisabled community-dwelling persons, aged 70 years or older, who were interviewed monthly for 4 years to ascertain ADL disability. Estimates of active and disabled life expectancy were calculated using an increment-decrement life table for assessment intervals of 1 month, 1 year, and 2 years. RESULTS: For each of five age groups, the monthly assessment strategy yielded the highest values for active life expectancy and the lowest values for disabled life expectancy. The 95% confidence intervals for these values, however, overlapped the corresponding point estimates for the annual and biennial strategies. CONCLUSIONS: Accurate estimates of active and disabled life expectancy may be obtained from epidemiologic studies that assess ADL function no more frequently than every other year.

Activities of Daily Living↗

Modifiable impairments predict progressive disability among older persons.

UNLABELLED: Our purpose was to determine the extent to which a predetermined set of modifiable impairments predicted progression of disability. METHOD: We conducted a 3-year follow-up of two community-based cohorts of older adults. The impairment areas included lower extremity, upper extremity, hearing, vision, and affect. Home management and social or productive activities were the domains of function investigated. RESULTS: All five impairments were of at least borderline significance in predicting decline in both functional domains in both cohorts with the exception of hearing for home management activities. The five impairments together explained from 17% to 23% of the decline seen in the functional outcomes (partial R(2)s 0.17 to 0.23). DISCUSSION: Five prevalent and potentially modifiable impairments explained much of the progressive disability experienced. Given the priority that older patients place on function as a health outcome, these impairments should be routinely assessed and modified.

Activities of Daily Living↗

Modifiable risk factors for nursing home-acquired pneumonia.

BACKGROUND: This study sought to identify modifiable risk factors for pneumonia in elderly nursing home residents. METHODS: A cohort of 613 elderly residents (age, >65 years) of 5 nursing homes in the New Haven, Connecticut, area was followed-up prospectively from February 2001 through March 2003. The primary outcome was radiographically documented pneumonia within a 12-month surveillance period. Baseline modifiable risk factors were evaluated for their independent association with pneumonia. RESULTS: Of 613 elderly nursing home residents, 131 (21%) died, and an additional 112 (18%) developed a radiographically documented case of pneumonia during the 12-month surveillance period. Among the 9 candidate modifiable risk factors that were evaluated individually in Cox proportional hazards models adjusting for covariates (i.e., nursing home facility, age, race, coexisting conditions, and immobility), inadequate oral care (hazard ratio [HR], 1.60; 95% confidence interval [CI], 1.06-2.35; P=.024) and swallowing difficulty (HR, 1.65; 95% CI, 1.04-2.62; P=.033) were associated with pneumonia. When modifiable risk factors were evaluated simultaneously in the same Cox proportional hazards model, inadequate oral care (HR, 1.55; 95% CI, 1.04-2.30; P=.030) and swallowing difficulty (HR, 1.61; 95% CI, 1.02-2.55; P=.043) remained independently associated with pneumonia, adjusting for the same covariates. Calculation of population-based attributable fractions showed that 21% of all cases of pneumonia in our cohort could have been avoided if inadequate oral care and swallowing difficulty were not present. CONCLUSIONS: Two biologically plausible and modifiable risk factors increased the risk of pneumonia in elderly nursing home residents. These results provide a framework for the development and testing of a targeted pneumonia prevention strategy.

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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↗

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↗

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↗

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↗

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↗

A program to prevent functional decline in physically frail, elderly persons who live at home.

BACKGROUND: Functional decline in physically frail, elderly persons is associated with substantial morbidity. It is uncertain whether such functional decline can be prevented. METHODS: We randomly assigned 188 persons 75 years of age or older who were physically frail and living at home to undergo a six-month, home-based intervention program that included physical therapy and that focused primarily on improving underlying impairments in physical abilities, including balance, muscle strength, ability to transfer from one position to another, and mobility, or to undergo an educational program (as a control). The primary outcome was the change between base line and 3, 7, and 12 months in the score on a disability scale based on eight activities of daily living: walking, bathing, upper- and lower-body dressing, transferring from a chair, using the toilet, eating, and grooming. Scores on the scale ranged from 0 to 16, with higher scores indicating more severe disability. RESULTS: Participants in the intervention group had less functional decline over time, according to their disability scores, than participants in the control group. The disability scores in the intervention and control groups were 2.3 and 2.8, respectively, at base line; 2.0 and 3.6 at 7 months (P=0.008 for the comparison between the groups in the change from base line); and 2.7 and 4.2 at 12 months (P=0.02). The benefit of the intervention was observed among participants with moderate frailty but not those with severe frailty. The frequency of admission to a nursing home did not differ significantly between the intervention group and the control group (14 percent and 19 percent, respectively; P=0.37). CONCLUSIONS: A home-based program targeting underlying impairments in physical abilities can reduce the progression of functional decline among physically frail, elderly persons who live at home.

Accidental Falls↗

Understanding the treatment preferences of seriously ill patients.

BACKGROUND: The questions patients are asked about their preferences with regard to life-sustaining treatment usually focus on specific interventions, but the outcomes of treatment and their likelihood affect patients' preferences. METHODS: We administered a questionnaire about treatment preferences to 226 persons who were 60 years of age or older and who had a limited life expectancy due to cancer, congestive heart failure, or chronic obstructive pulmonary disease. The study participants were asked whether they would want to receive a given treatment, first when the outcome was known with certainty and then with different likelihoods of an adverse outcome. The outcome without treatment was specified as death from the underlying disease. RESULTS: The burden of treatment (i.e., the length of the hospital stay, extent of testing, and invasiveness of interventions), the outcome, and the likelihood of the outcome all influenced treatment preferences. For a low-burden treatment with the restoration of current health, 98.7 percent of participants said they would choose to receive the treatment (rather than not receive it and die), but 11.2 percent of these participants would not choose the treatment if it had a high burden. If the outcome was survival but with severe functional impairment or cognitive impairment, 74.4 percent and 88.8 percent of these participants, respectively, would not choose treatment. The number of participants who said they would choose treatment declined as the likelihood of an adverse outcome increased, with fewer participants choosing treatment when the possible outcome was functional or cognitive impairment than when it was death. Preferences did not differ according to the primary diagnosis. CONCLUSIONS: Advance care planning should take into account patients' attitudes toward the burden of treatment, the possible outcomes, and their likelihood. The likelihood of adverse functional and cognitive outcomes of treatment requires explicit consideration.

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