Propuesta de mejora para el profesorado

In 1963 Sidney Katz published work describing the development and

application of the Index of Independence in Activities of Daily Living (IADL) – a standardized measure of function for the elderly and chronically ill (Katz S, Ford A et.al. 1963). Katz notes that the changes in function (as measured by the IADL) were sequential, for example, going to the toilet independently could only follow if the person was able to transfer (from bed and chair) independently. This early paper focused on recovery of function. Katz

hypothesized that just as there is an orderly pattern of development, there is an ordered regression as part of the natural process of aging (ibid p918).

The connection between ADLs and predicting care needs appears in the paper of Branch and Ku (1989) who identify activities of daily living (ADL) scores and hospitalizations as the most useful predictors of need for long term care, based on a 10 year longitudinal study of 1625 community dwelling elderly people. Such information, as emphasized in the paper, can be used as the basis for actuarial estimates for long-term care policies and insurance, public, private or self-funded. After all, according to these authors:

An additional concern when insuring people is estimating differential risks based on their characteristics at the time of enrollment. Understanding these risks reduces the potential for “adverse selection”, that is, disproportionate enrollment by those most likely to need the services (Branch L and Ku L 1989, p372). These authors present their research as a tool for insurers to identify high risk clients.

Referencing the research of Branch and Katz, Bortz (1990) published a

retrospective review of the hospital records of 97 patients of a geriatric service (acute setting) to identify the trajectory of dying, based on their functional status. Bortz identifies the need to characterize life not just by its duration but by quality (Bortz W 1990, p146). He also refutes the notion that the elderly cost too much in the acute setting, arguing that cost of hospital care has a direct

Page 77 of 242 relationship to functional status and younger age. That is, older and

dysfunctional patients had lower dying bills than those who were younger and more vital (Bortz W 1990, p147). However he also acknowledges that this may be due to rationing, implicit or explicit, of high cost services such as ICU to these patients. Bortz reviewed the records of all his patients that had died in the preceding 12 months for demographics, diagnoses, medicine use, evidence of advanced directives, length of stay and functional status based on his own three point score based on what was in the record (that is, not necessarily measured at the time of the patient’s life) or his memory. The results found, that similar to the study done with community elders (Branch L, Katz S et.al. 1984), functionality is maintained into the last year of life, and rationing health care on the basis of age is inappropriate. There is no reference in this paper to the Glaser and Strauss trajectory, and the term trajectory is used in regard to quality of life.

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The work of Branch, but not Bortz, is extensively referred to in a paper by Crimmins and Saito (1993) that is itself cited 145 times (Google Scholar October 2012). The paper, titled “Getting Better and Getting Worse; transitions in functional status among older Americans” publishes the results of a two year study done in 1986 of 3,169 community living elders aged 70 and older.

Crimmins and Saito measured 21 indicators of ability to care for themselves independently – in the home and outside the home. They use the term transition in relation to a major finding of their research, that older individuals can both lose and regain the ability to perform specific functions (Crimmins E and Saito Y 1993) . Also, as described by Bortz (1990), while age is related to the

likelihood that functioning will deteriorate, the decline is worse when the person has poor general health and a significant physical impairment, such as stroke (Crimmins and Saito, 1993).

Functional transitions and transitory fluctuations in physical function in relation to hospitalizations are reported in a paper by Mor (Mor V, Wilcox V et.al. 1994). This research supported the finding by Crimmins and Saito, that

Page 78 of 242 functional status in the elderly is not simply downhill, and also found that there is a link between functional decline and hospital use, especially in the period immediately prior to death. The term, trajectory of decline is used in a paper by Zarit (Zarit S, Johansson B et.al. 1995) that reported the results of a four year (three measurement intervals) longitudinal study of initially 324, 84 – 90 year old people. This study combined measures of physical function (personal care and instrumental care, such as using a washing machine) with measures of cognitive function (Figure 2.10). The authors state that this hadn’t been done before. Figure 2.10 From Zarit et.al.1995, p9: Development of disability in the elderly

Zarit describes that over time, the measured changes in functioning declined considerably in that over each measured two year interval, one half of

participants who had no significant disability had declined or died. Also while decline was the main trend, a small number improved in functioning between intervals, supporting the findings of previous authors. What is important about these studies is that they have identified the risk of using simple, population based studies of disability. For example Zarit found that while there was a high incidence of disability there was, at the same time, a low prevalence of

disability. That is while participant disability increased, they also died. The paper by Crimmins and Saito (Crimmins E and Saito Y 1993) also found, that disability in women increased compared to men, but looking deeper than population level, that this is due to women living longer and hence also more likely to enter institutional care than men. These findings have important

Page 79 of 242 implications for costing the future care of the elderly. As Payne notes, the role of age, morbidity, and death in health care expenditures … is not a uniform picture (Payne G, Laporte A et.al. 2007, p 248) because while people may live to beyond ninety and the cost of their death is less than for a younger cohorts, their overall use of health services is also extended (Payne G, Laporte A et.al. 2007).

This body of literature also uses the terms ‘transitions’ and ‘trajectory’.

However, while there are similarities with the Glaser and Strauss monographs, there is no reference to any author between the threads from either literature. Arguably the most important point to emerge from the literature reviewed in this section is that functional decline does not have a simple relationship with age or time. In the section to follow, Joanne Lynn argues the same point in relation to the functional decline experienced by a dying person and has drawn three representative trajectories of functional decline to death.