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Original Investigation
April 8, 2019

Association of Functional Impairment in Middle Age With Hospitalization, Nursing Home Admission, and Death

Author Affiliations
  • 1Division of Geriatric Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
  • 2Geriatrics and Extended Care Program, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
  • 3Division of Geriatrics, University of California, San Francisco
  • 4Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center, San Francisco, California
  • 5Statistical Editor, JAMA Internal Medicine
JAMA Intern Med. 2019;179(5):668-675. doi:10.1001/jamainternmed.2019.0008
Key Points

Question  When difficulty performing basic activities of daily living (“functional impairment”) develops in middle-aged adults, is it associated with an increased risk of adverse outcomes including hospitalization, nursing home admission, and death?

Findings  In this nationally representative matched cohort study of 5540 community-dwelling adults, those who developed functional impairment between ages 50 and 64 years were at increased risk of hospitalization, nursing home admission, and death compared with those without functional impairment.

Meaning  Even in relatively young people, functional impairment has important clinical implications.


Importance  Difficulty performing daily activities such as bathing and dressing (“functional impairment”) affects nearly 15% of middle-aged adults. Older adults who develop such difficulties, often because of frailty and other age-related conditions, are at increased risk of acute care use, nursing home admission, and death. However, it is unknown if functional impairments that develop among middle-aged people, which may have different antecedents, have similar prognostic significance.

Objective  To determine whether middle-aged individuals who develop functional impairment are at increased risk for hospitalization, nursing home admission, and death.

Design, Setting, and Participants  This matched cohort study analyzed longitudinal data from the Health and Retirement Study, a nationally representative prospective cohort study of US adults. The study population included 5540 adults aged 50 to 56 years who did not have functional impairment at study entry in 1992, 1998, or 2004. Participants were followed biennially through 2014. Individuals who developed functional impairment between 50 and 64 years were matched by age, sex, and survey wave with individuals without impairment as of that age and survey wave. Statistical analysis was conducted from March 15, 2017, to December 11, 2018.

Exposures  Impairment in activities of daily living (ADLs), defined as self-reported difficulty performing 1 or more ADLs, and impairment in instrumental ADLs (IADLs), defined similarly.

Main Outcomes and Measures  The 3 primary outcomes were time from the first episode of functional impairment (or matched survey wave, in controls) to hospitalization, nursing home admission, and death. Follow-up assessments occurred every 2 years until 2014. Competing risks survival analysis was used to assess the association of functional impairment with hospitalization and nursing home admission and Cox proportional hazards regression analysis was used to assess the association with death.

Results  Of the 5540 study participants (2739 women and 2801 men; median age, 53.7 years [interquartile range, 52.3-55.2 years]), 1097 (19.8%) developed ADL impairment between 50 and 64 years, and 857 (15.5%) developed IADL impairment. Individuals with ADL impairment had an increased risk of each adverse outcome compared with those without impairment, including hospitalization (subhazard ratio, 1.97; 95% CI, 1.77-2.19), nursing home admission (subhazard ratio, 2.62; 95% CI, 1.99-3.45), and death (hazard ratio, 2.06; 95% CI, 1.74-2.45). After multivariable adjustment, the risks of hospitalization (subhazard ratio, 1.54; 95% CI, 1.36-1.75) and nursing home admission (subhazard ratio, 1.73; 95% CI, 1.24-2.43) remained significantly higher among individuals with ADL impairment, but the risk of death was not statistically significant (hazard ratio, 1.06; 95% CI, 0.85-1.32). Individuals with IADL impairment had an increased risk of all 3 outcomes in adjusted and unadjusted analyses.

Conclusions and Relevance  Similar to older adults, middle-aged adults who develop functional impairment appear to be at increased risk for adverse outcomes. Even among relatively young people, functional impairment has important clinical implications.

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