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Preventing or minimizing functional dependency in older adults rests, in part, upon the ability to predict who is at risk. The purpose of this study was to compare the ability of five tests of hand function to discriminate the degree of dependency in older adults. Seven hundred sixty four subjects were assessed for hand function on performance-based (Williams Test of Hand Function, a test of Williams Board items only, Jebsen Test of Hand Function, grip strength), and self-reported (Dexterity Scale of the Geriatrics-Arthritis Impact Measurement Scale (GERI-AIMS] measures of hand function, and self-reported multidimensional functional status (GERI-AIMS). A trichotomous variable representing a continuum of dependency based upon living site (independent living, home-bound, institutional) was used as the measure of dependency. Sixty-two cases were dropped for incomplete data. Discriminant function analyses of the 702 subjects (age X = 76.78 years, SD = 8.79) showed that basic demographic variables explain 40.8% of the variance in dependency; all hand function tests significantly correlated with dependency; the Williams Board correlated best (additional 12.5% variance explained). However, a multidimensional functional status measure explains substantially more variance in dependency (16.9%) after controlling for demographic variables and performance on the Williams Board. This comparison of methods and tests available for measuring hand function was made to provide criteria for selecting an instrument for a given setting.

OBJECTIVES: To examine the effect of a more-efficient home care protocol to manage total joint replacement (TJR) patients after surgery. DESIGN: A randomized trial of two home care protocols for TJR management. SETTING: A hospital-affiliated home healthcare agency in a large midwestern city. PARTICIPANTS: Medicare-eligible individuals undergoing elective total hip or knee replacement surgery (N = 136). INTERVENTION: A home care protocol that included preoperative home visits by a nurse and a physical therapist and fewer postoperative visits (range of 9–12 visits) to the home than an existing protocol (range of 11–47 visits). MEASUREMENTS: Functional status, lower extremity functioning, health-related quality of life, satisfaction with care, and use and cost of healthcare services for 6 months postsurgery. RESULTS: There were no differences in functional status, health-related quality of life, or lower extremity functioning by group at 6 months. A marginally significant gain in satisfaction with access to care (P = .059) was found in the intervention group at 6 months. Home healthcare costs were 55% lower for the streamlined group (P < .001). Other costs did not differ significantly by group. CONCLUSION: TJR patients who received the more-efficient home care protocol experienced comparable outcomes to those who received the existing protocol. An abbreviated set of home care visits resulted in more-efficient delivery of care without compromising patient outcomes.

OBJECTIVE: To determine factors that predict decline in manual performance using a multivariate model of determinants of functional limitation. DESIGN: Longitudinal observational study. SETTINGS: Ambulatory general medicine clinics, residences of homebound individuals, and a continuing care retirement community. PARTICIPANTS: Subjects were 485 persons more than 60 years of age and included continuing care retirement community (CCRC) residents (n = 215), chronically homebound older persons (n = 65), and ambulatory older adults (n = 205). Mean age at baseline was 78 years. MEASUREMENT: Independent variables included demographics, physician measures of upper-extremity joint impairment, comorbidities derived from physical examination and chart abstract, self-assessed arthritis pain, depression, and anxiety. The major dependent variable was 2-year decline in timed manual performance below a threshold associated with need for long-term care services. RESULTS: The proportion of subjects who exceed a Timed Manual Performance Test threshold of 350 seconds increased slowly from baseline through Year 4 for all age groups but rose rapidly from Year 4 to Year 6 for the oldest group (>85 years at baseline). Using a discrete survival model, we found that age, education, grip strength, and psychological status predicted crossing the manual performance threshold within a 2-year period. CONCLUSIONS: The findings, coupled with earlier findings that upper extremity joint impairment predicted both grip strength and manual performance, suggest that joint impairment may be an important risk factor for future functional limitation. Since diminished hand function has been shown to predict dependency, development and testing of interventions to maintain or restore upper extremity joint function and reduce pain would appear to be a high research priority.

OBJECTIVE: To determine factors that predict change in walking velocity in older people using a multivariate model. DESIGN: Longitudinal observational study. SUBJECTS: A total of 588 persons older than age 60, including subjects residing in a continuing care retirement community (CCRC) (n = 248), and homebound (n = 79) and ambulatory (n = 261) subjects. Mean age at baseline = 77. MEASUREMENT: Independent variables included demographics, physician measures of lower-extremity joint impairment and other musculoskeletal and neurological variables, comorbidities derived from physical examination and chart abstract, self-assessed arthritis pain, depression, and anxiety. The major dependent variables were 2- and 4-year decline in walking velocity below a threshold associated with nursing home placement. MAIN RESULTS: From baseline to Year 4, median walking velocity declined from 61.8 to 53.0 m/min, and the proportion of subjects above a threshold value of 11.5 m/min declined from 95.3% to 80.4%. Age, joint impairment, and weakness of quadriceps, measured at baseline, predicted 2-year and 4-year decline in walking velocity. CONCLUSIONS: The findings indicate that joint impairment and quadriceps strength contribute significantly to crossing a clinically significant threshold in walking velocity among older people over time. Future research is needed to determine whether these risk factors can be modified through preventive interventions such as muscle-strengthening exercises and pain medication. J Am Geriatr Soc 44:126–132, 1996.

Objective: To test the impact of joint impairment on ambulation in the elderly, using a multivariate model. Design: Cross-sectional observational study (baseline data from an ongoing longitudinal study). Subjects: Five hundred thirty-two persons over age 60, including continuing care retirement community (CCRC) (n = 222), homebound (n = 63), and ambulatory (n = 247) respondents. Mean age at assessment = 76.6 (SD = 6.6). Measurement: Independent variables included sociodemo-graphics, physician measures of lower joint impairment, an index of cormorbidities derived from physical examination or chart abstract, self-assessed arthritis pain, depression, and anxiety. The dependent variable, ambulation, was measured as walk-rate, based on the time required to walk 50 feet. Main Results: For the total sample, 61% of the subjects were impaired in more than one lower joint group, with almost 50% of the homebound impaired in more than three joint groups. Demographics (particularly age and education) explained much of the variance in walk-rate. After controlling for demographics and membership in the groups purposely sampled (CCRC, homebound, ambulatory), lower joint impairment accounted for an additional 7% of the variance in walk-rate. Total amount of variance explained by the model was 56% (Adjusted R2 = .56). A 3-point change in lower joint impairment score, equivalent to the maximum impairment score for a single joint group, is associated with a 4-second change in the mean time required to walk 50 feet. The knee and lower spine joints contributed most to the impact of the lower joint impairment measure. Conclusions: Among the elderly, age and education are strong predictors of performance on a walk-rate test. Independent of demographics and non-musculoskeletal conditions, joint impairment is associated with diminished walking ability in this population.

Objective To test the contribution of joint impairment to observed hand function (grip strength and Williams Test) in the elderly, using a multivariate model. Design Cross-sectional observational data (baseline data from an ongoing longitudinal study). Subjects Five hundred forty-one persons over age 60, including continuing care retirement community (n = 222), homebound (n = 72), and ambulatory (n = 247) respondents. Mean age at assessment 76.7, (SD = 9.0). Measurement Independent variables included sociodemographics, physician measures of upper joint impairment, an index of comorbidities derived from physical examination or chart abstract, self-assessed arthritis pain, depression, and anxiety. The dependent variables included grip strength and a modified Williams Test [Williams Test (M)]. Main Results The multiple regression explained 59% (Adjusted R2 = .59) of the variance in grip strength, with joint impairment accounting for a change in R2 of .07. Upper joint impairment and grip strength accounted for 3% and 5%, respectively, of the variance in the Williams Test (M) (total amount of explained variance = 45%). Conclusions Demographics explain most of the variance in grip strength and performance on the Williams Test (M). Controlling for demographics, musculoskeletal disease represented by joint impairment is associated with diminished grip strength. Reduced grip strength is associated with poorer performance on the Williams Test (M).