Review articleMedication Use and Functional Status Decline in Older Adults: A Narrative Review
Introduction
Functional status is the cornerstone of geriatric care and serves as an indicator of general well-being. The World Health Organization's International Classification of Functioning, Disability, and Health describes the health status of a person in terms of body functions and structures, activities, and participation in life situations. An impairment or limitation in any of these functional capacities, whether due to underlying illness or personal or environmental factors, can be problematic for older adults.1 Specifically, a decline in function can increase health care use, worsen quality of life, threaten independence, and increase the risk of mortality.2, 3, 4, 5 As such, functional status has been recognized as a relevant and important treatment outcome in the elderly population.4, 6, 7, 8, 9
There are 2 primary ways to measure functional status: self- or caregiver-reported or performance-based measures. Three of the most commonly used self- or caregiver-reported measures are (1) basic activities of daily living ([BADL] eg, bathing, dressing, getting around the house, toileting, feeding, grooming),10 (2) instrumental activities of daily living ([IADL], eg, using the telephone, paying bills, taking medications, preparing light meals, doing laundry, shopping, housekeeping, mode of transportation, ability to handle finances)11, and (3) mobility (ie, walking one-half mile, walking up and down stairs, doing heavy work around house).12 Typically, mobility is the first functional status measure to show decline, whereas BADL is the last. Derivations of these self- or caregiver-reported measures include the 36-Item Short Form Health Survey (SF-36) Physical Functioning domain, which combines 4 scales (ie, physical functioning, physical role, bodily pain, self-rated health) with scores from 0 to 100 (higher scores indicate better function).13 The Karnofsky Performance Status measure assigns scores ranging from 0 (dead) to 100 (perfect health).14 Finally, persistent lower extremity limitation is operationally defined as 2 reports over a 6-month period of difficulty walking one-fourth mile or climbing 10 steps without resting.15
Performance-based measures may be particularly useful in evaluating older adults at the upper end of the functional spectrum who would otherwise report little or no physical limitation.16, 17 One such measure, gait speed, is both a predictor of adverse outcomes and an indicator of physical frailty in older adults.18, 19 A recent pooled analysis of >34,000 older adults found a significant association between gait speed and survival.16 Gait speed can be analyzed alone20 and/or as part of the Short Physical Performance Battery (SPPB).21, 22 The SPPB evaluates balance, gait, strength, and endurance by testing one's ability to stand with feet together in 3 positions (ie, side by side, semitandem, and tandem), time required to walk 8 feet, and time required to rise from a chair and return to the seated position 5 times.17 Timed chair stands have been used alone to measure functional status,23 although the clinical significance of this measure by itself is unclear.24 Last, the Functional Independence Measure (FIM) is a widely accepted functional assessment measure in the rehabilitation community.25 Of the FIM's 18 items, 13 address physical domains and comprise the motor portion of the FIM.25, 26 Each item is scored based on the observed level of assistance required to perform BADL and IADL, with lower scores indicating the need for more assistance.26 Progress may be described in terms of relative FIM motor gains: [FIM gain/(maximal possible FIM – actual admission FIM)].27
Risk factors for functional status decline are numerous and include advanced age, low income, poor self-rated health, presence of comorbidities or certain medical conditions (eg, arthritis, cognitive impairment, depression), lifestyle habits (eg, lack of physical activity, current or past smoking, no or excessive alcohol consumption), and medication use.28, 29 Multiple potential physiologic explanations exist to elucidate the impact of medications on functional outcomes.9, 30, 31 For example, it has been suggested that specific medications may increase the risk of impaired functional status by adversely affecting such domains as alertness, vision, and muscle strength.30, 31 With medication use being a potentially modifiable risk factor for functional status decline, it is important to understand whether there is consistency across studies. Given this background, the objective of this study was to examine the potential risk of medication use on functional status decline in the elderly.
Section snippets
Materials and Methods
The MEDLINE and EMBASE databases were searched for English-language articles published from January 1986 to June 2011. Search terms included aged, humans, drug utilization, polypharmacy, inappropriate prescribing, anticholinergics, psychotropics, antihypertensives, drug burden index, functional status, function change or decline, activities of daily living, gait, mobility limitation, and disability. A manual search of the reference lists of the identified articles and the authors' article
Results
A total of 2157 articles were identified by the literature search. Nineteen studies were identified for inclusion in this review. The individual studies were categorized into the following subsections: suboptimal prescribing, benzodiazepines, anticholinergics, nonbenzodiazepine psychotropics, multiple central nervous system (CNS) drugs, and antihypertensives. These studies are summarized in Table I, Table II, Table III, Table IV, Table V, Table VI by category. Below we provide a brief
Discussion
To the best of our knowledge, this is the first systematic review of the risk of functional status decline with medication use in older adults. We found that for the majority of studies (ie, 1419 studies), medication use, regardless of the drug class, was associated with worse functional status. Of the 19 studies identified, only 2 were randomized trials.20, 94 Of these, 1 found a statistically significant effect, whereas the other did not. Less than half of the studies (ie, 8/19 studies)
Conclusions
Benzodiazepine and anticholinergic use has been consistently linked to impairments in functional status in the elderly. The impact of suboptimal prescribing, antidepressants, and antihypertensives on functional status decline was mixed. Future studies are needed to further evaluate the impact of medication use on functional status in older adults.
Acknowledgments
This study was primarily supported by National Institute on Aging grants and contracts (U01 AG00678121, R01 AG027017, P30 AG024827, T32 AG021885, K07 AG033174, R56 AG027017, R01 AG034056), a National Institute of Mental Health grant (R34 MH082682), a National Institute of Nursing Research grant (R01 NR010135), an Agency for Healthcare Research and Quality grants (R01 HS017695, R01 HS018721, K12 HS019461), and a VA Health Services Research grant (IIR-06-062).
Dr. Peron conducted the literature
References (97)
- et al.
The association between psychotropic medication use and functional outcome of elderly hip-fracture patients undergoing rehabilitation
Arch Phys Med Rehabil
(2005) - et al.
Risk factors for functional status decline in community-living elderly people: a systematic literature review
Social Sci Med
(1999) - et al.
Potential adverse outcomes of psychotropic and narcotic drug use in Canadian seniors
J Clin Epidemiol
(1997) - et al.
Physiologic, psychologic, and health predictors of 6-minute walk performance in older people
Arch Phys Med Rehabil
(2002) - et al.
Relation between use of angiotensin-converting enzyme inhibitors and muscle strength and physical function in older women: an observational study
Lancet
(2002) - et al.
Appropriate prescribing in elderly people: how well can it be measured and optimised?
Lancet
(2007) - et al.
Geriatric pharmacotherapy and polypharmacy
- et al.
Efficacy of oxycodone/acetaminophen and codeine/acetaminophen vs. conventional therapy in elderly women with persistent, moderate to severe osteoarthritis-related pain
Arch Gerontol Geriatr
(2009) ICF: International Classification of Functioning, Disability and Health
(2001)- et al.
Disability in older adults: evidence regarding significance, etiology, and risk
J Am Geriatr Soc
(1997)
Lower-extremity function in persons over the age of 70 years as a predictor of subsequent disability
N Engl J Med
Designing randomized, controlled trials aimed at preventing or delaying functional decline and disability in frail, older persons: a consensus report
J Am Geriatr Soc
Declining diability among the elderly
Health Affairs
Functional outcomes for clinical trials in frail older persons: time to be moving
J Gerontol Med Sci
Indications, labeling, and outcomes assessment for drugs aimed at improving functional status in older persons: a conversation between aging researchers and FDA regulators
J Gerontol Med Sci
The effects of polypharmacy in older adults
Clin Pharm Ther
Progress in the development of the index of ADL
Gerontologist
A Guttman health scale for the aged
J Gerontol
The MOS 36-item short-form health survey (SF-36)I. Conceptual framework and item selection
Med Care
Measuring health-related quality of life in older patient populations: a review of current approaches
Pharmacoeconomics
Central nervous system medication use and mobility limitation in community elders: the Health, Aging and Body Composition study
Pharmacoepdemiol Drug Saf
Gait speed and survival in older adults
JAMA
A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission
J Gerontol
Assessment of function and disability in longitudinal studies
J Am Geriatr Soc
Prognostic significance of potential frailty criteria
J Am Geriatr Soc
The effects of antidepressants on obstructed and unobstructed gait in healthy elderly people
J Gerontol A Biol Sci Med Sci
Drug Burden Index Score and functional decline in older people
Am J Med
Associations between Drug Burden Index and physical function in older people in residential aged care facilities
Age Ageing
Association between antihypertensive medication use and non-cardiovascular outcomes in older men
J Gen Intern Med
A 30-s chair-stand test as a measure of lower body strength in community-residing older adults
Res Q Exerc Sport
The FIM(TM)The Center for Outcome Measurement in Brain Injury
The relationship between comprehensive functional assessment and optimal pharmacology in the older patient
DICP
Practical aspects of drug treatment in elderly patients with mobility problems
Drugs Aging
Implications and management of decline for the elderly patient
Consult Pharm
Effects of long-term use of benzodiazepines on gait and standing balance in the elderly
Ann N Y Acad Sci
Drug burden index to define the functional burden of medications in older people
Arch Intern Med
Anticholinergic drugs and physical function among frail elderly population
Clin Pharmacol Ther
Impact of inappropriate drug use on physical performance among a frail elderly population living in the community
Eur J Clin Pharmacol
Serum anticholinergic activity and motor performance in elderly persons
J Gerontol A Biol Sci Med Sci
Physical and cognitive performance and burden of anticholinergics, sedatives, and ACE inhibitors in older women
Clin Pharmacol Ther
Drug Burden Index and physical function in older Australian men
Br J Clin Pharmacol
Use of proton-pump inhibitors and their associated risks among frail elderly nursing home residents
Scand J Prim Health Care
Effects of human growth hormone in men over 60 years old
N Engl J Med
Systematic review: The safety and efficacy of growth hormone in the healthy elderly
Ann Intern Med
Effects of an oral growth hormone secretagogue in older adults
J Clin Endocrinol Metab
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