Article / PURPOSE: To determine the prevalence of disability in Peru, explore dependency on caregiver's assistance and assess access to rehabilitation care. METHOD: Data from Disability National Survey (ENEDIS), including urban and rural areas, were analyzed. Disability was defined as a permanent limitation on movement, vision, communication, hearing, learning/remembering or social relationships. Dependency was defined as the self-reported need for a caregiver to help with daily activities; and access to rehabilitation care was defined as the self-report of any therapy for disabilities. Estimates and projections were calculated using sample strata, primary sampling units and population weights, and prevalence ratios (PRs) and 95%CI were reported. RESULTS: From 798 308 people screened, 37 524 (5.1%; 95%CI 4.9--5.2%) had at least one disability. A total of 37 117 were included in further analysis, mean age 57.8 (SD ± 24.1) years, 52.1% women. Dependency was self-reported by 14 980 (40.5%; 95%CI: 39.2-41.9%) individuals with disabilities. A family member, usually female, was identified as a caregiver in 94.3% (95%CI: 93.3-95.3%) of dependent participants. Only 2881 (10.7%; 95%CI: 9.7-11.9%) of people with disabilities reported access to rehabilitation care. Major inequality patterns of disability burden versus access to rehabilitation care were observed by age and education level. Older age groups had higher disability burden yet lower chances of access to rehabilitation care. Conversely, the higher the education level, the lesser the overall disability burden but also the higher chances of reporting receiving care. Private healthcare insurance doubled the probability of having access to rehabilitation compared with those without insurance. CONCLUSIONS: Approximately 1.6 million Peruvians have at least one disability, and 40% of them require assistance with daily activities. Informal caregiving, likely female and relative-provided, is highly common. Rehabilitation care access is low and inequitable. Our results signal a major need to implement strategies to guarantee the highest standard of health care for people with disabilities. Implications for Rehabilitation Major inequality patterns in terms of burden of disability versus access to rehabilitation care were observed: those groups who concentrate more disability reported receiving less rehabilitation care. Caregiving is mostly informal and provided by a direct relative, mainly a woman, who resigned to their usual activities in order to help care for the person with disability. As a result, there is a need to develop appropriate support and training for caregivers. Access to care services in Peru is low and inequitable, but especially for people with disabilities: they experience greater barriers when accessing healthcare services even in the case of having health insurance. / Revisión por pares

Abstract Sheltered housing for the elderly is an intermediate type of housing, between living in ones own home and living in an institution. The aim of this study was to describe the changes in physical, cognitive and psychological abilities among the elderly living in sheltered housing during a two-year follow-up period. In this study psychological abilities were represented by depressive symptoms. The changes in the abilities of the elderly people living in sheltered housing were compared with the corresponding changes among the elderly living in their own homes. Furthermore, the associated factors and the predictors of the decline in physical and cognitive abilities, as well as the depressive symptoms were examined. The control group consisted of elderly people who were matched with those living in sheltered housing in regard to age, sex, coping with activities of daily living and depressive symptoms. The data of this study were collected among elderly people living in 20 units of sheltered housing in Finland in 1994 and 1996. 725 residents were interviewed and 340 re-interviewed after two years. Cognitive capacity was assessed with the help of the Mini-Mental Examination test (MMSE). Depressive symptoms were assessed using the shortened version of the Zung Self-rating Depression Scale (ZSDS). The results showed that the elderly living in sheltered housing were widows or widowers and lived alone more often than the home-dwelling elderly. They perceived their health as poorer, had less contacts with other people and had fewer hobbies than the elderly living at home. Nevertheless, they felt less lonely and were more satisfied with their lives than those living at home. During the two-year follow-up period the decline in the functional capacity of the elderly living in sheltered housing did not essentially differ from the corresponding change among the home-dwelling elderly. The decline in physical and psychological abilities among the elderly living in sheltered housing was similar to the decline among those living at home. Even if the decline in cognitive abilities among the elderly living in sheltered housing was more rapid than the change among the home-dwelling elderly, the difference between the groups was slight. Living in sheltered housing appeared to have neither a negative nor a positive effect on the functional capacity of the elderly. The predictors of the physical decline among the elderly living in sheltered housing were a high age, poor physical abilities at baseline, a high number of depressive symptoms, the use of medication and a low number of hobbies. The predictors of the physical decline among the home-dwelling elderly were the female sex, a high age, poor physical abilities at baseline, a high number of depressive symptoms, health perceived as poor and low social participation. The predictors of the decline in cognitive abilities among the elderly living in sheltered housing included a high age, poor cognitive abilities at baseline, poor education, dissatisfaction with life and health perceived as good. Among the home-dwelling elderly the predictors of the decline in cognitive abilities were poor cognitive abilities at baseline and a low number of hobbies. Among the elderly living in sheltered housing the predictors of depressive symptoms included a high number of depressive symptoms at baseline, poor cognitive abilities, health perceived as poor, a high number of feelings of loneliness, a low number of visits paid to other people and high education. Among the home-dwelling elderly the predictors of depressive symptoms were a high number of depressive symptoms at baseline and a high age.

Alzheimer's disease (AD) is the most common cause of dementia initially characterised by short-term memory deficits followed by a progressive cross domain cognitive and functional decline over time and loss of independence in carrying out activities of daily living (ADL). Apathy and depression are also the two most frequent neuropsychiatric sequalae associated with AD and have an impact on patients' ability to execute ADLs. Little is still known if apathy subdomains differently predict ADL performance in these patients. In this study, we aimed to quantitatively investigate if global apathy and depression predict ADL performance. We also wanted to establish if the apathy evaluation scale (AES) items resolve into three factors as proposed by Marin and if those factors differently predict performance of ADLs. We recruited a sample of 115 patients diagnosed with probable or possible AD. Basing on current literature, we hypothesised that apathy and depression predict ADL performance. We also hypothesised that AES items will load into three factors relating to cognitive, behavioural and affective apathy subdomains and that these subdomains will differentially predict ADL performance in our patient sample. Our results indicated that high apathy and depression symptoms were associated with problems to carryout ADLs. They also indicated that AES items resolved into a three factor solution in analogy with Marin's conceptualisation but they did not cluster in the manner that he proposed. Finally, when these factors are regressed simultaneously, (derived from factor analysis) only behavioural apathy significantly predicted ADLs.

This study examined the relationship between five neurocognitive domains, including memory, visual-spatial skills, executive functioning, language, and attention, and three instrumental activities of daily living (IADLs), (financial management, medication management, and driving), as well as three basic activities of daily living (ADLs), including dressing, feeding, and grooming. Subjects were community dwelling older adults diagnosed with Alzheimer's Disease (AD) ranging in severity from mild to severe. Correlation and regression models were used to analyze the relationship between neurocognitive domains and self-care activities. All of the neurocognitive domains were significantly but mildly correlated with declines in IADLs, and all of the neurocognitive domains, except memory, were significantly but mildly correlated with ADL decline. None of the regression models, except driving, produced significant results. The hypotheses were based on the belief that overlap occurs between declines in cognitive domains and self-care skills. The results of this study support the assertion that global cognitive decline occurs followed by declines in IADLs and later declines in ADLs. Thus, instead of specific neurocognitive domains predicting decline in individual self-care skills, this research indicates that the degree of severity of cognitive decline is predictive of impairments in IADLs or ADLs with milder global impairment predicting IADLs and more pronounced decline predicting declines in ADLs. Degree of severity may have been more predictive because while individuals vary in cognitive symptom presentation, the course of AD always progresses from mild to more severe. The role of over-learning also potentially impacted the results of the study. Individuals learn and daily practice ADLs at a young age causing them to require less higher level cognitive skills (over-learned). Since over-learned IADLs require less higher level cognition, they were preserved longer in AD course, thus declining after global cognitive impairment. Clinicians need to thoroughly assess the degree to which an individual has over-learned a task in order to make the most accurate recommendations. If an individual has milder global decline, IADLs are likely to be impaired, and if an individual has moderate global decline with memory reaching a floor, ADLs are likely to be impaired.

The overarching theme of this thesis is the prevention of progressive-type disability. Unlike catastrophic disability, progressive disability is gradual and more common in older adults. Because progressive disability can take years to develop, it is often conceptualized as a continuum, from less to more disabled. Disability prevention, by definition, is designed to identify people who are as yet nondisabled but at high risk for future functional decline by identifying an early functional state associated with increased risk of subsequent disability (Fried & Guralnik, 1997). This thesis sought to address two challenges associated with identifying an early functional state of disability. The first challenge relates to instrument calibration. Traditional instruments (based on self-report) used for assessing disability, scales of activities of daily living (ADL) and instrumental activities of daily living (IADL), were originally developed to describe levels of functional status in institutionalized older adults. Thus, these instruments poorly discriminate, as well as underestimate disability in the early stages of development. Poor discrimination refers to tasks or activities (i.e., scale items) that prove unresponsive to changes in a particular person’s ability level. Performance measures on the other hand, such as walk time or grip strength, have proven to be quite responsive to early declines in functional status. Despite the popularity of performance measures used to assess health status in epidemiology or gerontological research, evidence suggests that they measure a somewhat different construct than self-reported activities of daily living. ADLs have a long history of use in the medical community, yet it has been proposed that the relative standing of ADLs, in relation to communitydwelling older adults, could be enhanced by improving construct validities that are at least equivalent to those of physical performance measures. Item response theory (IRT) methodology can be used to improve the structure of ADL scales so that they are more sensitive in detecting the early stages of functional decline within relatively high functioning older adults; a stage that has been shown to be more responsive to clinical interventions aimed at prevention of overt disability or frailty. IRT can improve ADL scales in multiple ways: by confirming an underlying uni-dimensional continuum of disability, establishing interval level measurement or item hierarchies, and increasing scale precision. As part of this thesis I conducted a systematic review of functional status scales, applied to community-dwelling older adults, which employed IRT procedures. The review was useful in that it draws attention to areas of functional assessment that can be improved upon, most notably, the topic of establishing interval level data and construct under-representation. Using data from the Cardiovascular Health Study, I was able to show that a common hierarchy of functional decline was observed for a diverse set of conditions and diseases that are prevalent among community-dwelling older adults. Such an indicator could be used to identify hierarchical declines relating to severity in diverse patient populations. Improvements in validity of functional status scales can also lead to the use of ADL-IADLs as potential determinates of disability, rather than simply acting as outcome measures of disability. Again using data from the Cardiovascular Health Study, I examined the predictive power of IADL (mobility-type) items on later disability. Self reported difficulty in 2 or 3 of the most difficult IADL items increased the odds of being disabled eight years later by a factor of 3.5. The odds of being disabled fell to 1.9 for those reporting difficulty with one item. The second challenge of this thesis relates to defining determinants of functional decline that manifest themselves at the earliest stages of the disablement process. As previously stated physical performance measures have been shown to be sensitive to early stages of functional decline. However, can other measures, potentially spanning multiple domains, be used to identify those at high risk for future disability? In particular I was interested in whether psychosocial and cognitive variables could be used to detect changes in functional status at the preclinical stages of the disablement process. With regard to the Cardiovascular Health Study, I was able to show that, for subjects within the normal range of cognitive functioning, performance in the lowest quartile of the Digit Symbol Substitution Test resulted in a 2.2 increase in the odds of being disabled. Performance on this measure, as well as selfreported mobility noted above, could detect decrements in functional status as much as 8 years prior. With the use of the Lothian Birth Cohort sample I explicitly investigated the psychosocial domain. I found that the level of depressive symptoms increased the odds of being disabled by 56%. Again, these symptoms were assessed as much as eight years prior to self-reported disability. The general findings of this thesis indicate that refinements in ADL-IADL measures can aid in the detection of disability at the pre-clinical level, and that cognitive function and intra-individual factors play a pivotal role in speeding up or slowing down the disablement process.

I–HOPE is an instrument that can be used to examine person–environment fit in the home. The instrument is developed in the United States and involves forty-four activity cards that are to be sorted by the client to address the activities that are problematic in his/her everyday life. The purpose of this study was to examine if the activity cards would fit in a Swedish context, and if other activities needed to be added, to match every day activities of people, 65 years and older, living in ordinary homes in Sweden. A survey was distributed to twenty-one participants age 65 and older. This survey was conducted in a project with Luleå University of Technology and the University of Gothenburg, that aims to adapt I-HOPE to be applicable in Sweden. Results show that nineteen of the forty-four activity cards were identified by all the participants. Further, eighteen more cards were identified by the majority of the participants. The seven activity cards that were not identified, or were done in a different way than what the picture showed, contained multiple activities that were categorized into one, compared to the ones that were identified. Additionally, the participants identified two more activities, that they felt, the instrument lacked. These results conclude that I-HOPE contains some valid activities, but needs to be adapted further, to fit a Swedish context, and to work as an occupational instrument for elders, ageing in place.

Activities of Daily Living (ADL) are important indicators of both cognitive and physical well-being in healthy and ill humans. There is a range of methods to recognise ADLs, each with its own limitations. The focus of this research was on sensing location-driven activities, in which ADLs are derived from location sensed using Radio Frequency (RF, e.g., WiFi or BLE), Magnetic Field (MF) and light (e.g., Lidar) measurements in three different environments. This research discovered that different environments can have different constraints and requirements. It investigated how to improve the positioning accuracy and hence how to improve the ADL recognition accuracy. There are several challenges that need to be addressed in order to do this. First, RF location fingerprinting is affected by the heterogeneity smartphones and their orientation with respect to transmitters, increasing the location determination error. To solve this, a novel Received Signal Strength Indication (RSSI) ranking based location fingerprinting methods that use Kendall Tau Correlation Coefficient (KTCC) and Convolutional Neural Networks (CNN) are proposed to correlate a signal position to pre-defined Reference Points (RPs) or fingerprints, more accurately, The accuracy has increased by up to 25.8% when compared to using Euclidean Distance (ED) based Weighted K-Nearest Neighbours Algorithm (WKNN). Second, the use of MF measurements as fingerprints can overcome some additional RF fingerprinting challenges, as MF measurements are far more invariant to static and dynamic physical objects that affect RF transmissions. Hence, a novel fast path matching data algorithm for an MF sensor combined with an Inertial Measurement Unit (IMU) to determine direction was researched and developed. It can achieve an average of 1.72 m positioning accuracy when the user walks far fewer (5) steps. Third, a device-free or off-body novel location-driven ADL method based upon 2D Lidar was investigated. An innovative method for recognising daily activities using a Seq2Seq model to analyse location data from a low-cost rotating 2D Lidar is proposed. It provides an accuracy of 88% when recognising 17 targeted ADLs. These proposed methods in this thesis have been validated in real environments.

With aging there is a decrease in a person’s ability to perform activities of daily living (ADL) which may be most effectively addressed using training patterns that are biomechanically similar to ADL. Since aquatic exercise offers the opportunity to provide resistance with a high level of safety, the pool may afford the ideal environment for ADL-specific training in an aging population. Purpose: The purpose of this investigation was to compare a traditional aquatic exercise program (TRAD) to an aquatic program tailored to target ADL (ADLspec). Methods: Eighteen independently living individuals (68.7 + 7.5 years) were randomly assigned to a TRAD or ADLspec aquatic exercise group. The exercise groups attended 1 hr exercise sessions, 2 times per week for 8 weeks. ADL ability was assessed using the short version of the Continuous-Scale Physical Functional Performance Test (PFP-10); while strength and power were assessed using the 30s arm curl and 30 sec. chair stand tests. Results: Mixed design ANOVAs revealed a significant group x time interaction for floor sweep time with the ADLspec group outperforming the TRAD and control (CON) groups (p = .043). Additionally, the ADLspec group improved the pan weight and scarf time components of the PFP-10 (p < .020), while the TRAD group improved pan time and laundry time (p < .046). Both training groups showed similar improvements for jacket time, grocery weight, and 6-min walk, (p < .046). The ADLspec and TRAD groups also made similar improvements in upper and lower body strength, as well as lower body power across time, (p < .043). A student’s t-test revealed the TRAD group spent more time exercising during the hour session than the ADLspec group (p < .05). Conclusion: The results indicate that performing an ADLspec aquatic exercise program can increase performance of ADL that require more complex sequential movements; however, ADL more dependent on fitness may be better addressed using a TRAD intervention. These results can be helpful when designing a periodized aquatic training program to increase independence in older persons.

Near-fall detection is important for medical research since it can help doctors diagnose fall-related diseases and also help alert both doctors and patients of possible falls. However, in people’s daily life, there are lots of similarities between near-falls and other Activities of Daily Living (ADLs), which makes near-falls particularly difficult to detect. In order to find the subtle difference between ADLs and near-fall and accurately identify the latter, the movement of whole human body needs to be captured and displayed by a computer generated avatar. In this thesis, a wireless inertial motion capture system consisting of a central control host and ten sensor nodes is used to capture human body movements. Each of the ten sensor nodes in the system has a tri-axis accelerometer and a tri-axis gyroscope. They are attached to separate locations of a human body to record both angular and acceleration data with which body movements can be captured by applying Euler angle based algorithms, specifically, single rotation order algorithm and the optimal rotation order algorithm. According to the experiment results of capturing ten ADLs, both the single rotation order algorithm and the optimal rotation order algorithm can track normal human body movements without significantly distortion and the latter shows higher accuracy and lower data shifting. Compared to previous inertial systems with magnetometers, this system reduces hardware complexity and software computation while ensures a reasonable accuracy in capturing human body movements.

The purpose of this study was to determine the relationship of spinal deformity with physical function and self-perception in children with spina bifida. Ninety-eight eligible children with scoliosis and spina bifida were identified; 80 of them (82%) consented to participate. Spinal deformity was measured in many ways, including scoliosis, coronal balance, and pelvic obliquity. Measures of physical function included the Sitting Balance Scale, Jebsen Hand Scale, Hoffer Ambulation Scale, the Spine Bifida Spine Questionnaire, and the Activities Scale for Kids (ASK). Self-perception was determined with Harter's Self-Perception Profile. No relationship was found between spinal deformity and overall physical function (ASK). Of all aspects of spinal deformity, only coronal imbalance was significantly related to only one aspect of physical function (ie, sitting imbalance). No aspect of spinal deformity was related to self-perception. In conclusion, surgeons should be clear in their indications for surgery and recognize that in the short term the potential benefit of surgery may be, at best, to improve only sitting balance.