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Measurement and Conceptual Frameworks for Aging and Disability

Early efforts to measure disability among older people emerged from efforts toquantify function at the person level for rehabilitation (Frey, 1984). As noted above,aging has relied upon ADLs and IADLs. In 1959 Katz introduced Katz Activitiesof Daily Lying Scale (ADLs) (Benjamin Rose Hospital, 1959) that included sixmeasures: bathing, dressing, toileting, transfers, continence, and feeding (Katz,Ford, Moskowitz, Jackson, & Jaffe, 1963). Lawton(1971) expanded measures toinclude Instrumental Activities of Daily Living (IADLs) that characterized skillsrequired to live in the community. IADLs include shopping, food preparation,money management, housekeeping, and use of transportation. (See Cohen & Marino,2000, for review of disability measures.) Changes in ADLs and IADLs were usedto characterize changes in the rates of disability among older people.In the mid 1960s to the late 1970s, Nagi (1965) proposed a conceptual frameworkthat recognized the progression of disability. In the mid 1970s and early1980s, Wood (1975) and Wood and Badley (1980) proposed The InternationalClassification of Impairments, Disabilities and Handicaps: A Manual ofClassification Relating to the Consequences of Disease (World Health Organization,1980). A vigorous debate occurred in the disability community regarding the meritof the two models. In 2001 the World Health Organization published theInternational Classification of Functioning, Disability and Health (ICF) as one ofthe family of WHO international classifications to address various aspectsof health. In 2007, the Institute of Medicine study of disability, The Future ofDisability in America, recommended the ICF be adopted as of model of disability for monitoring and research (Field & Jette, 2007). (See Whiteneck, 2006 and Field &Jette, 2007 for further discussions of the ICF). The ICF has been widely adopted inEurope and has gained a considerable following in the disability community asdemonstrated in other chapters of this book. Gerontologists in theU.S. are debatingthe merit of the ICF model (Jette, 2009; Freedman, 2009). The chief merit of theICF is that it creates a common, systematic language to describe human experience,including outcomes, quality of life, and environmental factors (ICF, 2001). The ICFcan be employed to describe a person, groups, or populations, and it recognizes thedimensional characteristics of the disablement experience. The ICF has particularmerit for aging disability research because it can account for people moving intoand out of disability, and it captures the profound influence of the environment onparticipation and activity.

An example of the prevalence and effects of vision impairment and comorbidconditions illustrates the utility of the ICF in aging research (Crews, Jones, & Kim,2006). Tables presented people age 65 and older in four groups: those with novision loss and no severe risk of depression, those with vision loss only, those withsevere risk of depression only, and those with both vision loss and severe risk ofdepression (See Table 5). Four outcomes measures drawn from the ICF weredefined: moderate/severe difficulty walking  mile, moderate/severe difficultyclimbing ten steps, moderate/severe difficulty shopping, and moderate/severe difficultysocializing. Two outcomes represented activity restrictions in the ICF, andtwo represented participation measures in the ICF. Additional or other measurescould have been selected to represent these concepts. In this example, we demonstratedthat the effects of severe risk of depression and vision loss can be measuredas distinct concepts, and the combined effects of both conditions can be characterized. Comorbid conditions have a compounding effect in the ability to performactivities and participate in social roles at the population level. For example, about12.4% or people without vision loss and without severe risk of depression reportmoderate/severe difficulty walking one-quarter mile. For people with vision impairmentonly, 40.1% report moderate /severe difficulty walking one-quarter mile. Forpeople with severe depression risk only, 63.2% report difficulty walking onequartermile. Finally, those who report both vision loss and severe depression risk,74.0% report difficulty walking one-quarter mile. Therefore, difficulty walkingmoves from one in eight for those without vision or depression risk to three out offour for people with both. By selecting variables from activity limitations and participationrestrictions, we can demonstrate the dimensional effects of comorbidconditions. The ICF could be employed to identify environmental barriers andfacilitators as long as the data set contained those variables.

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