Profile of disability in elderly people: estimates from a longitudinal population study
BMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7191.1108 (Published 24 April 1999) Cite this as: BMJ 1999;318:1108All rapid responses
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EDITIOR: The study reported by Melzer et al. is important in
demonstrating the interrelations between acute and long term care -
especially in terms of the use of formal and informal community support.
It is particularly valuable in following up those identified as falling
within a threshold of 'disability' to explore dynamic relationships of
resource use. It is unfortunate that this presentation of the results did
not distinguish those who died in the follow up from those who survived.
The MIDSPAN longitudinal study (1) found a high concentration of acute
admissions - and the majority of hospital bed days - taking place within
12 months of death (of those dying within a 23 year follow up).
For the formulation of policy it is important to distinguish the two
different age effects - the level of support required as we are more
distant from birth - and the level of support required as we are closer to
death. Three reasons for this may be adduced:
- As life expectancy improves so the average number of years lived by
each person increases; but the average number of deaths died stays the
same. Hence, it is possible to overstate the impact of ageing on resource
need if we do not distinguish in our projections the 'perishers' from the
'survivors' at each age.
- Retrospective studies - e.g. the General Household Survey -
necessarily only capture 'survivors'. It is valuable to be able to
reconcile results from different samples.
- The recent experience of emergency bed pressures for adults appears
to derive largely from greatly increased admissions of patients aged 75
plus with acute breathing difficulties or syncope/collapse. Initial
analysis indicates a relationship to subsequent death. This suggests a
model of increasing acute hospital utilisation arising from a diminished
flexibility and capacity within community support networks to cope with
progressive or sporadic physical deterioration in the last 12 months of
life.
It would be useful to be able to test, and possibly track, such
dynamic effects within this longitudinal data set.
1. Hanlon P et al. Hospital use in an ageing cohort. Journal of
Public Health Medicine 20:4 pp 467-476.
Tom Hennell
Strategic Analyst
NHS Exec NW
Competing interests: No competing interests
A Valid and Reliable Cognitive Measure
In 1970, a global cognitive functioning theory was developed and a
framework of practice plus a battery of assessments were created by
Claudia Allen, MA, OTR, FAOTA. At USC in Los Angeles,USA.
The cognitive disability approach proposes an information processing
model of the aetiology of the functional impairment that identifies
different patterns of functional performance. Cognitive components such
as attention, praxis, and memory are incorporated into the Cognitive
Disabilities Model: however, they are more broadly conceptualised as
components of functional information processing patterns that vary
significantly throughout a hierarchy of functional levels (Levy, 1998)
A sequence of cognitive abilities is used to explain the severity of
the disability, and the impairment in thinking and feeling is observed in
behaviour.
Allen (1985, 1987) proposed a hierarchy of six cognitive levels. The
focus is on task performance and/or activity, the six levels are
considered to represent information processing that is regulated by
sensorimotor associations in the brain.
A decimal system was added and named the Modes of Performance. The
longer scale is sensitive to smaller changes in ability to function that
have important clinical consequences. The rating criteria describe
differences in what the person pays attention to, with the resulting motor
behaviour and speech performance. The cognitive levels and modes are
referred to as the Allen Cognitive Levels (ACL).
Aged people with a cognitive disability have experienced chemical or
structural changes in the brain that have damaged the more fragile Working
Memory, making it difficult if not impossible for many of them to attend
to any new form of learning.
I highly recommend this model of practice and its well
researched,reliable and valid measure, when you undertake further
population studies.
Competing interests: No competing interests