PATTERN AND RISK FACTORS OF FUNCTIONAL LIMITATION AND PHYSICAL DISABILITY AMONG COMMUNITY- DWELLING ELDERLY IN KUALA PILAH, MALAYSIA: A 12-MONTH FOLLOW-UP STUDY NORLIANA BINTI ISMAIL Malaya THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FORof THE DEGREE OF DOCTOR OF PUBLIC HEALTH FACULTY OF MEDICINE UNIVERSITY OF MALAYA UniversityKUALA LUMPUR 2016 ORIGINAL LITERARY WORK DECLARATION Name of Candidate: Norliana binti Ismail Registration/Matric No: MHC120003 Name of Degree: Doctor of Public Health Title of Thesis (―this Work‖): Pattern and risk factors of functional limitation and physical disability among community dwelling elderly: a 12-month follow-up study Field of Study: Public Health, Ageing, Epidemiology I do solemnly and sincerely declare that: (1) I am the sole author/writer of this Work; (2) This Work is original; (3) Any use of any work in which copyright exists was done by way of fair dealing and for permitted purposes and any excerpt or extract from, or reference to or reproduction of any copyright work has been disclosed expressly and sufficiently and the title of the Work and its authorship have been acknowledged in this Work; (4) I do not have any actual knowledge nor do I ought reasonably to know that the making of this work constitutes an infringement of anyMalaya copyright work; (5) I hereby assign all and every rights in the copyright to this Work to the University of Malaya (―UM‖), who henceforth shall be owner of the copyright in this Work and that any reproduction or use in any form or by anyof means whatsoever is prohibited without the written consent of UM having been first had and obtained; (6) I am fully aware that if in the course of making this Work I have infringed any copyright whether intentionally or otherwise, I may be subject to legal action or any other action as may be determined by UM. Candidate‘s Signature: ________________________ Date: ______________ Subscribed and solemnly declared before, Witness‘sUniversity Signature: _________________________ Date: ____________ Name: ____________________________________________________________ Designation: _______________________________________________________ ii ABSTRACT Functional limitation and physical disability are among the common geriatric conditions that can result in poor health, dependency and institutionalisation. Age-related disability and restriction in the elderly function has become one of the priorities in public health. However, the data on incidence and risk factors associated with functional limitation and physical disability in Malaysia and other developing regions are sparse. Most studies utilized a cross-sectional design which restricts the causal interpretation and inhibits a clear understanding of the relationship between risk factors and occurrence of both conditions. The objectives of this study were; 1) to determine the pattern; in terms of prevalence, incidence and incidence of recovery of functional limitation and physical disability, 2) to identify its associated risk factors, 3) to describe the subtypes of physical disability among community dwelling elderlyMalaya in Kuala Pilah, Malaysia. This was an observational population-based cohortof study with a twelve months follow-up. The study was conducted in Kuala Pilah district, Negeri Sembilan and elderly aged 60 years and above were selected and invited to participate in this study. The data on participants‘ risk factors and physical function status were collected during comprehensive, home-based assessments, which were completed at baseline and twelve months of follow-up. Disability was assessed during three monthly telephone interviews. Beside their socio-demographic characteristics, other risk factors assessed includeUniversityd depressive symptomology, cognitive impairment, social support level, self- reported visual impairment, history of fall and anthropometry measures. Outcome measures were assessed at twelfth months using validated tools for physical disability (Katz Activity of Daily Living and Instrumental Activity of Daily Living) and functional limitation (4-metre walking speed test). The overall prevalence of functional limitation was 62.8%, Instrumental Activity of Daily Living disability was 32.7% and Activity of Daily Living disability was 7.1%. The incidence of functional limitation at iii twelve months of follow-up was 38.4%, IADL disability was 24.8% and ADL disability was 4.8%. The common risk factors for incidence of functional limitation and physical disability were elderly women, advancing age and low educational level. The incidence of recovery from functional limitation at twelve months of follow-up was 31.5%, IADL disability was 34.2% and ADL disability was 43.9%. The most common disability subtype was short term disability, followed by transient disability, long-term disability and recurrent disability. The prevalence and incidence of functional limitation and IADL disability were common among elderly in Kuala Pilah, Malaysia. The prevalence and incidence of ADL disability were lower compared to elderly populations in developed countries. The findings from this study had provided clearer understanding on the relationship between specific impairments and risk factors to the development of functional limitation and physical disability. SpecificMalaya prevention and early therapeutic interventions can now be outlined in order to optimise function and reduce the disability among elderly. of University iv ABSTRAK Fungsi badan terhad dan ketidakupayaan fizikal adalah di antara masalah yang sering dihidapi oleh golongan warga emas. Keadaan ini boleh menyumbang kepada masalah kesihatan yang teruk, kebergantungan dan penempatan warga emas di institusi jagaan warga emas. Ketidakupayaan fizikal dan fungsi badan terhad adalah salah satu keutamaan di dalam bidang kesihatan awam. Walaubagaimanapun, data berkaitan insidens dan faktor penyebab kepada keadaan tersebut di Malaysia dan negara membangun yang lain adalah terhad. Kebanyakan kajian yang telah dijalankan sebelum ini adalah kajian prevalens dan ini membatasi pemahaman yang lebih jelas mengenai hubungan di antara faktor risiko dengan kedua-dua keadaan tersebut. Objektif kajian ini adalah; 1) Mengenalpasti corak (prevalens, insidens dan insidens sembuh) fungsi badan terhad dan ketidakupayaan fizikal, 2) MengenalpastiMalaya faktor risiko yang menyebabkan fungsi badan terhad dan ketidakupayaan fizikal,of 3) Mengenalpasti jenis ketidakupayaan fizikal di kalangan warga emas yang tinggal di Kuala Pilah, Malaysia. Kajian ini adalah kajian pemerhatian kohort di kalangan masyarakat selama 12 bulan. Kajian ini dijalankan di Kuala Pilah, Negeri Sembilan dan warga emas terpilih adalah yang berusia 60 tahun dan ke atas. Data berkaitan maklumat faktor risiko dan status fungsi fizikal diambil semasa temubual dijalankan dari rumah ke rumah pada awal permulaan kajian dan 12 bulan berikutnya. Ketidakupayaan fizikal juga dinilai dengan temubual melalui telefonUniversity kepada warga emas terpilih setiap tiga bulan. Selain sosio-demografik responden, faktor risiko yang lain juga dinilai seperti skala kemurungan, skala fungsi kognitif, skala tahap sokongan sosial, masalah penglihatan dan sejarah jatuh. Hasil kajian dinilai pada 12 bulan kemudiannya menggunakan skala ketidakupayaan fizikal (Katz Activity Daily Living dan Instrumental Activity Daily Living) dan fungsi badan terhad (ujian berjalan sejauh 4 meter). Prevalens keseluruhan untuk fungsi badan terhad adalah 62.8%, ketidakupayaan instrumental aktiviti kehidupan harian (IADL) 32.7% v dan ketidakupayaan aktiviti kehidupan harian (ADL) adalah 7.1%. Insidens fungsi badan terhad dalam tempoh 12 bulan berikutnya adalah 38.4%, ketidakupayaan instrumental aktiviti kehidupan harian (IADL) 24.8% dan ketidakupayaan aktiviti kehidupan harian (ADL) adalah 4.8%. Faktor risiko kepada insidens fungsi badan terhad dan ketidakupayaan fizikal adalah peningkatan umur, warga emas wanita dan tahap pendidikan yang rendah. Insidens sembuh daripada fungsi badan terhad dalam tempoh 12 bulan adalah 31.5%, ketidakupayaan instrumental aktiviti kehidupan harian 34.2% dan ketidakupayaan aktiviti kehidupan harian 43.9%. Jenis ketidakupayaan fizikal yang paling kerap adalah ketidakupayaan fizikal jangka pendek, diikuti oleh ketidakupayan fizikal sementara, ketidakupayaan fizikal jangka panjang dan ketidakupayaan fizikal berulang. Prevalens dan insidens untuk fungsi badan terhad dan ketidakupayaan instrumental aktiviti kehidupan harianMalaya adalah masalah yang biasa dialami oleh warga emas di Kuala Pilah, Malaysia. Prevalens dan insidens untuk ketidakupayaan aktiviti kehidupan harian adalahof rendah berbanding dengan warga emas di negara maju. Hasil pemerhatian yang diperolehi daripada kajian ini juga telah dapat menerangkan dengan lebih jelas hubungan di antara faktor risiko dengan kejadian fungsi badan terhad dan ketidakupayaan fizikal. Langkah pencegahan spesifik dan intervensi perawatan yang awal dapat dirancang dalam mengoptimakan fungsi dan mengurangkan ketidakupayaan fizikal di kalangan warga emas. University vi ACKNOWLEDGMENTS I would like to thank my husband, Megat Ridzuan Megat Amat and my children, Megat Afiq Najwan and Puteri Aina Zafirah, for all the love and encouragement they had provided me throughout this process. They had given me continuous support and always reminded me the importance of believing in myself. Without them, I would not be the person I am today. I would like to express my greatest gratitude to Associate Professor Dr Farizah Hairi and Associate