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Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.
The UK population is ageing. Disability in old age is frequent and lowers quality of life. Both mental and physical disability predispose to admission to hospital, need for residential care, and premature death. Helping to combat disability in the elderly can improve quality of life.
The World Health Organization has defined disability as the following:
"Disability is an umbrella term, covering impairments, activity limitations, and participation restrictions. An impairment is a problem in body function or structure; an activity limitation is a difficulty encountered by an individual in executing a task or action; while a participation restriction is a problem experienced by an individual in involvement in life situations. Thus disability is a complex phenomenon, reflecting an interaction between features of a person's body and features of the society in which he or she lives."
Activities of daily living (ADLs) include personal-care activities such as eating, bathing, dressing, and using the toilet.
Instrumental activities of daily living (IADLs) include household chores, shopping, managing medication, climbing stairs, public transport, finances and walking. They can be affected by cognitive impairment.
Frailty in the elderly is described as a state of global impairment of physiological reserves involving multiple organ systems. Frailty manifests as increased vulnerability, impaired capability to withstand intrinsic and environmental stressors, and limited capacity to maintain physiological and psychosocial homeostasis. Frailty is found in 20-30% of the elderly population aged over 75 years and increases with advancing age. It is associated with long-term adverse health-related outcomes such as increased risk of geriatric syndromes, dependency, disability, hospitalisation, institutional placement, and mortality.
In 2011, it was estimated that the number of people aged 65 and over was to increase by 65% over the following 25 years, with a doubling of the number of people aged >85 years. Managing older people's health effectively will be important.
The evidence for people aged <85 years tends to suggest that disability in the elderly is reducing, despite an increase in chronic diseases and conditions. For people aged >85 years, the trends regarding disability are less clear.
According to Canadian research, five types of chronic illness contribute largely to disability in people aged over 65 years:
- Foot problems
- Cognitive impairment
- Heart problems
Other common or important problems include:
- Hearing impairment.
- Chronic respiratory and cardiovascular disease such as chronic obstructive pulmonary disease (COPD), chronic heart failure, coronary heart disease and cerebrovascular disease.
- Falls and hip fracture.
In frail elderly people, a marked decline in physical and mental function can result from apparently small insults. This has been called the 'domino' effect, with a small initial insult leading to a cascade of adverse events.
Frailty in the elderly may be due to a combination of predisposing factors (early childhood development and lifestyle), followed by contributing factors such as physical inactivity, chronic disease, and anorexia/malnutrition in later adulthood.
One review in Brazil found that the main risk factors for functional disability in elderly people in the community were lack of schooling, rented housing, chronic diseases, arthritis, diabetes, visual impairment, obesity, poor self-perceived health, cognitive impairment, depression, slow gait, sedentary lifestyle, tiredness while performing daily activities, and limited diversity in social relations.These factors may be influenced by access to healthcare and the cost of healthcare in different countries.
The normal ageing process
Age is associated with a 1-2% decline in functional ability per year. Sedentary behaviour accelerates the loss of performance. Age-associated physiological changes include:
- Changes in body composition - reduction in muscle bulk and lean body mass, known as sarcopenia. Body fat may increase.
- Reduction in bone mass and strength with increased risk of fracture; osteoarthritic changes in joints.
- Reduction in blood volume, reduced tolerance of tachycardia; reduced ability to control blood pressure with postural change.
- Reduction in ventilatory capacity.
- Reduction in kidney function; impaired thirst mechanisms which increase susceptibility to dehydration.
- Reduced sensitivity to vitamin D and subsequent reduction in calcium absorption.
- Reduced motility of the large bowel; reduced hepatic mass and blood flow (which may affect hepatic metabolism of drugs).
- Nervous system changes, including reduction in cortical function and reduced motor and sensory peripheral nerve function; changes in autonomic function, including control of heart rate and temperature regulation (failure of normal response mechanisms to hot and cold).
- Reduced elasticity of the eye's lens; high tone hearing impairment.
People aged 70 years and over often have have one or more chronic conditions. Comorbidities may contribute to disability - for example:
- Stroke can lead to weakness, co-ordination problems, locomotor difficulties and problems of communication and continence.
- Coronary heart disease may lead to heart failure, angina or myocardial infarction.
- Diabetes - complications which can contribute to disability in a variety of ways (eg, the contribution of diabetic neuropathy to poor mobility) may be underestimated.
- Alzheimer's disease is the most common neurodegenerative disease. By the age of 85 years, 30% of the population has Alzheimer's disease.
- Urinary problems can be disabling, particularly if causing incontinence.
- Depression is often the result of disability but it also makes disability worse. 10-15% of people aged over 65 years living at home are depressed.
- Visual loss is associated with an increased risk of falling.
- Hearing and visual impairment increase the risk of social isolation and resulting depression.
- Falls are associated with injury, pain and loss of function. The prevalence of osteoporosis in the elderly population means that falls are more likely to result in fractures.
Assessment of a frail or disabled elderly person requires evaluation of:
- The damaged system.
- Other body systems.
- Medication - including polypharmacy.
- Function (such as ability to perform daily living activities):
- ADLs - eating/dressing/toileting/mobility.
- IADLs - dealing with medication/finances/housework/transportation.
- Environment - both the immediate environment (clothes and housing) and the locality (shops and social facilities).
- Formal and informal supports.
- Social and economic welfare.
Assessment by a specialist geriatrician and/or a multidisciplinary team specialising in elderly care can be useful.
A marked decline in function can be due to relatively small physiological insults, which may result in a frail older person being wrongly labelled as 'unable to cope'. Bear in mind that early comprehensive geriatric assessment and appropriate treatment may enable such patients to regain lost function.
Validated tools for assessment of disability or needs in elderly people include:
- Barthel's Index.
- Northwick Park Dependency Scale.
- Camberwell Assessment of Need in the Elderly.
Important aspects of management
- Treatment of unstable medical conditions and any treatable problems contributing to the disability.
- Reviewing drug treatment (including polypharmacy).
- Early mobilisation.
- Nutritional support.
- Comprehensive rehabilitation.
Who should be involved in management?
- A multidisciplinary approach can be helpful. This has been shown to be beneficial - eg, following stroke and fractured neck of femur. Geriatric day hospitals have been shown to be beneficial in providing care to elderly people with functional decline, although a Cochrane review found they may not have any clear advantage over other forms of comprehensive elderly medical services.
- 'Hospital at home' schemes have also been devised, although a Cochrane review found little evidence that they improved functional ability.
- 'Case management' by community matrons is a development in the care of elderly patients and those with long-term conditions. A review of this strategy concluded that this provision is at an early stage of development, and needs to develop effective links with a range of local services. The financial viability of this service is not clear.
Aspects of management
Treat contributing causes
Do not assume that age-related disability is untreatable. Look for and treat contributing problems (where feasible), such as:
- Uncontrolled cardiac, respiratory or metabolic disease - eg, heart failure, hypothyroidism.
- Reversible causes of hearing loss - eg, wax.
- Potentially treatable neurological disease - eg, tumours.
- Medication can contribute to both the problem of disability and the solution.
- Polypharmacy and increased susceptibility to drug side-effects are some of the issues surrounding medication in older people. See the separate Prescribing for the Older Patient article which discusses this topic in detail.
- Vitamin D deficiency should be recognised and treated in the elderly. The Department of Health has recommended that people over the age of 65 years take vitamin D supplements.
- Age alone is not a contra-indication for surgery.
- Operations such as joint replacement, cataract surgery and surgery for prostatic hypertrophy are frequently performed on the elderly to reduce disability.
Provision of aids and appliances
- Occupational therapy and the provision of aids can improve the quality of life. Home adjustments such as grip rails, stair lifts and removal of dangers such as loose carpets or inappropriate footwear can be helpful.
- Aids should be used to make the most of impaired vision or hearing.
- Glasses, low-vision aids such as magnifying glasses, large-print materials, talking clocks and watches, telephones with large numbers, audio books, and safety measures, such as raised-dot dials on kitchen equipment, may all be helpful.
- Hearing aids can greatly improve quality of life.
- Adapted safety devices may be needed (eg, flashing light on telephone or smoke alarm).
A paper discussing chronic pain in elderly people suggests that persistent pain in elderly patients is not simply a chronologically older version of younger pain.They suggest that interventions such as a 'mindfulness-based stress reduction programme' can be helpful.
Appropriate exercise can be part of pain management in some conditions - eg, osteoarthritis.
Social and environmental interventions
These may reduce the impact of the disability - for example:
- Financial support - eg, access to benefits and grants.
- Social support - eg, day centres, social activities and befriending.
- Housing support - appropriate accommodation can support independence and increase functional ability.
There is strong evidence of benefit to older people from Increasing physical activity, improved diet and nutrition and Immunisation and management programmes for influenza.
Exercise has some benefits in frail older people.Adapted exercise is beneficial for strength, mobility and balance and may reduce the risk of falls. This applies even to frail older people. Indirectly, physical activity may also increase well-being, social activity and mental health.
Evidence on the role of exercise in preventing disability
In terms of preventing disability, some trials involving physical exercise interventions reported positive outcomes for disability. However, differences between the trials can make it difficult to review the evidence or to make precise recommendations.[22, 23]
A review of disability from hip fracture suggested physical activity can protect against the risk of hip fracture among community-dwelling older adults.This may be via increased levels of vitamin D, or through the improvement of bone quality.
One editorial proposes 'assertive screening', using a single question to identify middle-aged and elderly people who are sedentary. These people could be invited to participate in lifestyle interventions including a prescription for exercise. It is suggested that a single question about a fall in the previous year is a method of identifying those who will benefit most.
How much exercise?
- The goal is to work towards 30 minutes of at least moderate-intensity physical activity on at least five days of the week.
- Two 15-minute periods of moderate activity daily may be a good way to start. If that is too much, take a 'little and often' approach, advising a gradual increase starting with just three minutes.
- The ideal is a combination of endurance exercises, strength exercises and stretching/balance/co-ordination exercises.
- It is never too late to start and any activity is better than none.
- Adequate warm-up is important and safe exercises/movement patterns should be chosen.
- Elderly people have relatively more body fat and less lean body mass, resulting in lower metabolic rates. Therefore, calorie needs are reduced, so the diet needs proportionately more protein, essential fats and micronutrients.
- Avoiding obesity is also beneficial.
- Aim to meet minimum nutritional requirements, provide adequate dietary fibre and address specific disease risks such as cardiovascular disease, stroke, diabetes and osteoporosis.
- Oral health and provision of dental treatment are important.
- Hospital nutrition - Age UK has campaigned for greater awareness of the problem of malnutrition in hospitalised elderly patients. Practical steps have been suggested - eg, a 'red tray' system to indicate which patients need assistance at mealtimes.
- Folic acid ± vitamin B12 has been suggested as possibly benefiting cognitive function in elderly people. However, a Cochrane review concluded that there is no consistent evidence either way, and more research is needed.
Screening and case finding
Are health checks useful?
The value of health checks for older people is uncertain:
- Annual checks by a nurse visit have shown benefit in mortality; however, not in UK studies.
- Case finding targets proactive care on individuals with a high level of need. Although interventions in this group are appreciated, a reduction in mortality or hospital admissions has not been shown.
- Screening programmes probably need to be intensive and sustained, if they are to deliver benefits.
- There is conflicting evidence regarding the benefits of preventative home visits to the elderly.[30, 31]
The British Geriatrics Society suggests that:
- A thorough assessment is needed for elderly people experiencing disability or a crisis.
- Otherwise, elderly people should be encouraged to follow healthy ageing advice.
Specific interventions include:
- Annual influenza immunisation (and pneumococcal vaccine for those with chronic conditions such as COPD).
- Regular eye checks - free for people aged over 60; two-yearly to age 60; annually from age 70.
- Hearing test - if a person's hearing is problematic or deteriorating.
- Disease screening for early diagnosis - eg, bowel cancer screening, abdominal aortic aneurysm screening, mammography, cervical cancer screening.
Healthy diet and lifestyle, including smoking cessation, should also be promoted.
Preventing falls and osteoporosis
See separate Prevention of Falls in the Elderly and Osteoporosis Risk Assessment and Primary Prevention articles.
Further reading and references
Better care for older people; General Medical Council (2014)
Older people: independence and mental wellbeing; NICE Guidance (December 2015)
The Older Person in the Accident & Emergency Department; British Geriatrics Society - Best Practice Guide 3.2 (May 2008)
Disabilities: definition; World Health Organization
Topinkova E; Aging, disability and frailty. Ann Nutr Metab. 200852 Suppl 1:6-11. Epub 2008 Mar 7.
Health and Social Care Bill Second Reading Briefing; Age UK, January 2011
Christensen K, Doblhammer G, Rau R, et al; Ageing populations: the challenges ahead. Lancet. 2009 Oct 3374(9696):1196-208.
Griffith L, Raina P, Wu H, et al; Population attributable risk for functional disability associated with chronic conditions in Canadian older adults. Age Ageing. 2010 Nov39(6):738-45. Epub 2010 Sep 1.
Marks R; Physical Activity and Hip Fracture Disability: A Review. Journal of Aging Research, 2011
Heppenstall CP, Wilkinson TJ, Hanger HC, et al; Frailty: dominos or deliberation? N Z Med J. 2009 Jul 24122(1299):42-53.
Rodrigues MA, Facchini LA, Thume E, et al; Gender and incidence of functional disability in the elderly: a systematic review. Cad Saude Publica. 200925 Suppl 3:S464-76.
Burton LA, Sumukadas D; Optimal management of sarcopenia. Clin Interv Aging. 2010 Sep 75:217-28.
Rehabilitation of Older People; British Geriatrics Society - Best Practice Guide 1.4 (revised 2009)
Pereira SR, Chiu W, Turner A, et al; How can we improve targeting of frail elderly patients to a geriatric day-hospital rehabilitation program? BMC Geriatr. 2010 Nov 310:82.
Siegert RJ, Turner-Stokes L; Psychometric evaluation of the Northwick Park Dependency Scale. J Rehabil Med. 2010 Nov42(10):936-43.
Brown L, Forster A, Young J, et al; Medical day hospital care for older people versus alternative forms of care. Cochrane Database Syst Rev. 2015 Jun 236:CD001730. doi: 10.1002/14651858.CD001730.pub3.
Shepperd S, Doll H, Angus RM, et al; Admission avoidance hospital at home. Cochrane Database Syst Rev. 2008 Oct 8(4):CD007491.
Challis D, Hughes J, Berzins K, et al; Implementation of case management in long-term conditions in England: survey and case studies. J Health Serv Res Policy. 2011 Apr16 Suppl 1:8-13.
Chapman L, Smith A, Williams V, et al; Community matrons: primary care professionals' views and experiences. J Adv Nurs. 2009 Aug65(8):1617-25. Epub 2009 Apr 28.
Karp JF, Shega JW, Morone NE, et al; Advances in understanding the mechanisms and management of persistent pain in older adults. Br J Anaesth. 2008 Jul101(1):111-20. Epub 2008 May 16.
Williams NH, Amoakwa E, Burton K, et al; The Hip and Knee Book: developing an active management booklet for hip and knee osteoarthritis. Br J Gen Pract. 2010 Feb60(571):64-82.
Gine-Garriga M, Roque-Figuls M, Coll-Planas L, et al; Physical exercise interventions for improving performance-based measures of physical function in community-dwelling, frail older adults: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2014 Apr95(4):753-769.e3. doi: 10.1016/j.apmr.2013.11.007. Epub 2013 Nov 27.
Crocker T, Forster A, Young J, et al; Physical rehabilitation for older people in long-term care. Cochrane Database Syst Rev. 2013 Feb 282:CD004294. doi: 10.1002/14651858.CD004294.pub3.
Howe TE, Rochester L, Neil F, et al; Exercise for improving balance in older people. Cochrane Database Syst Rev. 2011 Nov 9(11):CD004963. doi: 10.1002/14651858.CD004963.pub3.
Campbell AJ; Assertive screening: health checks prior to exercise programmes in older people. Br J Sports Med. 2009 Jan43(1):5. Epub 2008 Oct 16.
Young A, Dinan S; Activity in later life. BMJ. 2005 Jan 22330(7484):189-91.
Rivlin RS; Keeping the young-elderly healthy: is it too late to improve our health through nutrition? Am J Clin Nutr. 2007 Nov86(5):1572S-6S.
Malouf R, Grimley Evans J; Folic acid with or without vitamin B12 for the prevention and treatment of healthy elderly and demented people. Cochrane Database Syst Rev. 2008 Oct 8(4):CD004514.
Health Checks and Case Finding - Best Practice Guide; British Geriatrics Society (May 2010)
Kronborg C, Vass M, Lauridsen J, et al; Cost effectiveness of preventive home visits to the elderly: economic evaluation alongside randomized controlled study. Eur J Health Econ. 2006 Dec7(4):238-46.
Huss A, Stuck AE, Rubenstein LZ, et al; Multidimensional preventive home visit programs for community-dwelling older adults: a systematic review and meta-analysis of randomized controlled trials. J Gerontol A Biol Sci Med Sci. 2008 Mar63(3):298-307.