Disability in older people

See also the separate Prevention of falls in the elderly and Prescribing for the older patient articles.

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.

Some definitions

The World Health Organization has defined disability as the following:¹

"Disability is an umbrella term, covering impairments, activity limitations, and participation restrictions. In other words, disability is not just one health problem. It is a complex phenomenon, reflecting the interaction between features of a person’s body and features of the society in which he or she lives."

Frailty is defined as a clinical state, more common with increasing age, and characterised by decreased physiological reserve and an increased vulnerability to stressors. However, in spite of agreed consensus on a definition of frailty, it remains a globally poorly understood condition by the general public, older people living with frailty themselves, the care sector, politicians, senior healthcare leaders, and the wider NHS. There is a need for global understanding of what it means as a clinical condition, how it overlaps with other long- term conditions, how it may present differently, and how this can impact on multiple pathways and services.²

Frailty is found in 10% of those aged over 65 and up to half of those aged over 85. It is associated with long-term adverse health-related outcomes such as an increased risk of geriatric syndromes, dependency, disability, hospitalisation, falls, institutional placement, and mortality.²

Epidemiology

Disability is more common with older age - in the 2021 census, 47% of women and 38% of men aged over 90 said that they were 'limited a lot' by disability, compared to 8.8 of women and 6.8% of men aged 50 - 54. ³ The Office for National Statistics (ONS) estimates that 2.7% of the population of the UK are currently aged 85 or over and that this will have increased to by nearly half to 4.3% by 2043. ⁴ As the population ages, managing older people's health effectively will be important.

Disability causes (aetiology)⁵⁶⁷⁸

Common causes of disability in older adults include the following:

• Musculoskeletal problems and reduced mobility.

• General reduction in stamina and increase in fatigue.

• Cognitive impairment

• Chronic respiratory and cardiovascular disease such as chronic obstructive pulmonary disease (COPD), chronic heart failure, coronary heart disease and cerebrovascular disease.

• Impairment of vision and hearing.

• Falls and fractures.

• Bladder and bowel problems.

• Malnutrition and dehydration.

• Mental health conditions.

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.⁹

Disability risk factors

Frailty in elderly patients 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.⁹

The normal ageing process

Age is associated with a 1-2% decline in muscle mass and function per year. ^{10 11}Sedentary behaviour accelerates the loss of performance.¹² Age-associated physiological changes include:

• Changes in body composition - reduction in muscle bulk and lean body mass, known as sarcopenia. ¹³Body fat may increase. ¹⁴

• Reduction in bone mass and strength with increased risk of fracture; ¹⁵ osteoarthritic changes in joints. ¹⁶

• Reduction in blood volume, reduced tolerance of tachycardia; reduced ability to control blood pressure with postural change.¹⁷

• Reduction in ventilatory capacity.¹⁸

• Reduction in kidney function; impaired thirst mechanisms which increase susceptibility to dehydration. ¹⁹

• Reduced absorption to vitamin D and subsequent reduction in calcium absorption.²⁰

• Reduced motility of the large bowel; reduced hepatic mass and blood flow (which may affect hepatic metabolism of drugs).²¹

• 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). ²²

• Reduced elasticity of the eye's lens and changes in ocular biomechanical properties;²³ high tone hearing impairment.²⁴

Comorbidities

People aged 70 years and over often 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 dementia is the most common neurodegenerative disease and leads to significant health and social care needs.

• 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

The Comprehensive Geriatric Assessment (CGA)²⁵ is a tool which can be used to assess elderly patients, but an assessment takes up to two hours and so it is not appropriate for use in primary care.

It includes evaluation of:

• Physical assessment.

• Functional, social, and environmental assessment.

• Psychological components.

• Medication review.

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, measuring the degree of assistance required by an individual on ten mobility and activity of daily living items. It would be carried out by a physiotherapist or occupational therapist rather than by a GP. ²⁶

• Nottingham Extended Activities of Daily Living Scale - this is a short questionnaire which could be given to a patient to fill in before a GP appointment.²⁷

• The Timed Up and Go Test (TUGT). The patient is asked to stand up from a chair, walk 3 metres, turn around, walk back to the chair and sit down. If this takes more than 12 seconds, the adult is at risk for falls. ²⁸

Disability treatment and management

General points⁹²⁵

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 advantageous in developing a proactive approach to assessments and reducing the number of unplanned hospital admissions and may include care in a day hospital.²⁵

• Admission avoidance 'hospital at home' schemes with the option of transfer to hospital, may provide an effective alternative to inpatient care for a select group of elderly patients requiring hospital admission.

• 'Case management' by community matrons is a development in the care of elderly patients and those with long-term conditions.

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 - e.g. Parkinson's and dementia, for which treatment may improve symptoms or slow progression, even if no cure is available.

Drug treatment

• Medication can contribute to both the problem of disability and to 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 which are usually bought over the counter.

Surgical treatment

• Age alone is not a contra-indication for surgery, but when there are significant comorbidities or frailty, the benefits of surgery need to be carefully balanced against the risks.

• 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).

• Pain management

Persistent pain in elderly patients is probably not simply a chronologically older version of younger pain; older people have a different experience of pain and different pain processing mechanisms compared to their younger counterparts. Interventions such as a mindfulness, cognitive behavioural therapy, relaxation, and pain neuroscience education may be useful.²⁹³⁰ This is supported by brain imaging studies, which demonstrate that regulation of pain by cognitive and meditative therapies can alter the functioning of brain regions. ³¹³²

Appropriate exercise can be part of pain management in some conditions - eg, osteoarthritis.³³

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.

A social prescribing link worker will usually be the person in primary care who is most up to date with the availability of different options.

Disability prevention

There is strong evidence of benefit to older people from increasing physical activity, improved diet and nutrition and influenza vaccination.

Exercise

Exercise has some benefits in frail older people, whether they are living in their own home or in long-term care.^{34 35} 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 the improvement of balance and prevention of disability and fractures.³⁶³⁷³⁸

How much exercise?
The UK Chief Medical Officers' Guidelines advise:³⁹

• Older adults (those aged 65 and older) should participate in daily physical activity, with even light activity giving health benefits compared to being sedentary.

• Each week older adults should aim to accumulate at least 150 minutes of moderate-intensity aerobic activity, building up gradually from current levels. Those who are already regularly active can achieve these benefits through 75 minutes of vigorous-intensity activity, or a combination of moderate and vigorous activity, to achieve greater benefits. Weight-bearing activities help to maintain bone health.

Nutrition⁴⁰

• 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. It advocates that organisations across sectors and settings must ensure that they have robust processes in place for raising awareness of risk, prevention, recognition, measuring, monitoring, and treatment of malnourishment. This must include providing help and support with eating and drinking for people when they need it .

• 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. There is currently no public health recommendation that these be taken daily at a population level, but from December 2026 folic acid will be added to flour in the UK. This is however more aimed at preventing birth defects such as spina bifida than at improving the health of older adults.⁴¹⁴²

Screening and case finding²⁵

Are health checks useful?
There is little evidence to support the use of random health checks in the elderly. However, there is evidence that a CGA as described above is effective in reducing mortality and improving independence for older people admitted to hospital as an emergency compared to those receiving usual medical care. Furthermore, in community settings, the evidence suggests that complex interventions in people with frailty can reduce hospital admission and the risk of readmission in those recently discharged.

The BGS advocates that a CGA should be performed by the GP in a variety of situations, but in reality this is not practical due to the length of the assessment. It is generally secondary care or community teams who have the time to carry out a full CGA.

Preventing falls and osteoporosis

See the separate Prevention of falls in the elderly and Osteoporosis risk assessment and primary prevention articles.