The Rotterdam Study
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LOCOMOTOR DISABILITY IN THE ELDERLY An epidemiological study of its occurrence and determinants in a general population of 55 years and over The Rotterdam Study E.ODDING ISBN 90-9007582-8 Cover: Detail of "Life of the Hermits of Thebaid", Bonamico Buffalmacco (1340) Photography by Karel P. de Rooy Printing: Offsetdl1lkkerij Haveka B. V., Alblasserdam LOCOMOTOR DISABILITY IN THE ELDERLY An epidemiological study of ils occurrence and delerminants in a general populalion of 55 years and over The Rotterdam Study LOCOMOTORE BEPERKINGEN BIJ OUDEREN Een epidemiologisch onderzoek naar de prevalenlie en delerminanlen in een algemene bevolkillg boven de 55 jaar PROEFSCHRIFT ler verkrijging van de graad van doclor aan de Erasmus Universiteit Rotterdam op gezag van de rector magnificus Prof. Dr. P.W.C. Akkermans M.A. en volgens besluil van het College voor Promolies. De openbare verdediging zal plaalsvinden op woensdag 19 oklober 1994 om 11.45 lIUf door ELSEODDING geboren Ie Eindhoven PROMOTIE COMMISSIE Promotores: Prof. Dr. H.A. Valkenburg Prof. Dr. A. Hofman Overige leden: Prof. Dr. Sj. van del' Linden Prof. Dr. B. van Linge en te ervaren dat het verhaal van ons leven den slag van het water gaat krijgen dat wij rijpen bij wind en weer. dan slaat ook de gloed niet zo Heht meer met snelle en vluehtige slagen naar buiten in gelaeh en geween; Vir 'Brief aan een vriend' H. Marsman Verzamelde gedichten (1938) In dankbare herinnering aan Geert, Elsje, Jan en Hendrikje. Voo'\ Acknowledgments The Rotterdam Study is supported by grants from the Municipality of Rotterdam, the NESTOR programme for research in the elderly (Ministry of Health and Ministry of Education), the Netherlands Prevention Fund, the Netherlands Organisation for scientific research (NWO), the Netherlands Heart Foundation and the Rotterdam Medical Research Foundation (ROMERES). The publication of this thesis was financially supported by Het Nationaal Reumafonds, Het Anna Fonds and the Rotterdam Medical Research Foundation (ROMERES). CONTENTS Page 1 INTRODUCTION 11 2 IMPAIRMENT AND DISABILITY 15 2.1 Concepts and their mutual interrelation 17 2.2 Review of some disability-indices used in rheumatology 23 2.3 Review of the literature on the relationship between osteoarthritis and disability 37 2.4 Problems and hypotheses 45 3 POPULATION AND METHODS 49 3.1 The Rotterdam Study 51 3.2 Ascertainment of locomotor impairments 61 3.3 Ascertainment of locomotor disability 67 3.4 Participation in the Rotterdam Study 71 4 DISABILITY 75 4.1. Prevalence estimates of disability 77 4.2. The association between locomotor disability and joint complaints 93 4.3. The association between locomotor disability and radiological osteoarthritis of the hips and knees 105 4.4. The association between locomotor disability and physical abnormalities of the hips and knees 117 5 PARTICIPATION AND MEASUREMENTS 129 5.1 Influence of non-participation and other forms of selection on prevalence and association estimates 131 5.2 Self-assessed versus physician-assessed disability and pain 141 6 GENERAL DISCUSSION 149 7 SUMMARY 165 8 SAMENVATTING 171 APPENDICES 177 DANKWOORD 199 ABOUT THE AUTHOR 201 Manuscripts based in the studies described in this thesis Paragraph 4.1 Odding E, Valkenburg HA, Algra D, Vandenouweland FA, Grabbee DE, Hofman A. Disability in a Dutch general population of 55 years and over: the Rotterdam Study. Submitted. Pa,:agraph 4.2 Odding E, Valkenburg HA, Algra D, Vandenouweland FA, Grabbee DE, Hofman A. The association of locomotor complaints and disability in the Rotterdam Study. Submitted. Paragraph 4.3 Odding E, Valkenburg HA, Algra D, Vandenouweland FA, Grabbee DE, Hofman A. Associations of osteoarthritis of the hip and knee with locomotor disability in the Rotterdam Study. To be submitted. Paragraph 4.4 Odding E, Valkenburg HA, Algra D, Vandenouweland FA, Grabbee DE, Hofman A. Abnormalities on physical examination of the hip and knee and locomotor disability in the Rotterdam Study. To be submitted. Chapter 5 Odding E, Valkenburg HA, Algra D, Vandenouweland FA, Grabbee DE, Hofman A. Self-reported and physician observed disability in elderly people - The Rotterdam Study. To be submitted. CHAPTER 1 INTRODUCTION Chapter 1 INTRODUCTION Since the beginning of this century life-expectancy has increased by several decades. In 1990 newborn boys and girls in the Netherlands had a life-expectancy of 73 and 78 years respectively, compared to 51 years for boys and 53 years for girls born in 1910.' The consequences are twofold. Firstly, with stable birthrates the elderly become an ever-larger proportion of the population.' Secondly with the improvement of health care which can prevent premature death, the number of elderly people with chronic disease and disability steadily grows. Little is known about the burden of this on the health care system and on society as a whole, In a few countries some aspects of chronic disease and disability have 3 8 been studied. - From 1986 to 1988 the Netherlands Central Bureau of Statistics studied physical disability in the Dutch population. Disability was defined as difficulties in some activities of daily living as a result of some underlying impairment.' At present no data are available on disability in the population at large, regardless of its cause. Disability can result from a wide array of organ impairments. A major organ of interest is the locomotor apparatus and more specifically the lower limbs. Locomotor disability is then defined as the amount of difficulty a person experiences when walking, climbing stairs, rising from a chair or bed or otherwise. In 1990 the Rotterdam Study started as a population survey in people 55 years and older in one district of the city of Rotterdam. This study is primarily designed as a prospective follow-up study on the occurrence and risk factors of chronic disease and disability in a cohort of 10,275 people.' This thesis presents the prevalence of disability and the relation with putative risk factors in the first 5,034 participants to the study. Special attention is paid to the relationship between musculoskeletal signs and symptoms and locomotor disability. In the second chapter a review is given on the concepts, the indices and the measure ment of disability and its relation with osteoarthritis. The chapter is concluded with the hypotheses which underlie the study. The third chapter presents an extensive description of the Rotterdam Study population and the ascertaimnent of locomotor impairment and disability. The fourth chapter describes the prevalence estimates, the association of 14 introduction disability with joint complaints, radiological osteoatthritis and the findings of physical examination of the hips and knees, In the fifth chapter the influence of non-response and other forms of cohort-reduction on prevalence estimates and associative measures are presented. The results of a comparison between self-assessed and physician-assessed disability is described. Finally the thesis is concluded with a general discussion and suggestions for future research, REFERENCES 1. Hofman A, Grobbee DE, Dejong PTVW, Vandenouweland FA. Determinants of disease and disability in the elderly: the Rotterdam Elderly Study. Eur J Epidcmiol 1991;7:403-22. 2, Central Bureau of Statistics. Maandstatistieken van de bevolking, 1900-1994, 3. Lawrence Re, Everett DF, Hochberg Me. Arthritis. In: Health Status and Well- Being of the elderly. National Health and Nutrition Examination Survey-I Epidemiologic Follow-up Study, Comoni-Huntley JC,Huntley RR, Feldman JJ Eds, Oxford University Press 1990. New York Oxford. Pg 136-51. 4, Jette AM, Branch LG, The Framingham Disability Study: II, Physical Disability among the aging, Am J Public Health 1981;71: 1211-6. 5, Pinsky JL, Branch LG, Jette AM, Haynes SG, Feinleib M et al. Framingham Disability Study: relationship of disability 10 cardiovascular risk factors among persons free of diagnosed cardiovascular disease, Am J Epidemiol 1985;122: 44-56, 6, Pinsky JL, Leaverton PE, Stokes III J, Predictors of good function: Ihe Framingham Study, J Chron Dis 1987;40:159S-67S. 7, Aniansson A, Rundgren A, Sperling L. Evaluation of functional capacity in activities of daily living in 70-year-old men and women, Scand J Rehab Med 1980; 12: 145-54, 8, Bergstrom G, Aniansson A, BjeUe A, Grimby G, Lundgren-Lindquist B, Svanborg A, Functional consequences of joint impairment at age 79, Scand J Rehab Med 1985;183-90, 9, Netherlands Central Bureau of Statistics, Physical disability in the population of the Netherlands 1986/1988. The Hague, SDU-publishersICBS-publications, 1990. CHAPTER 2 IMPAIRMENT AND DISABILITY 2.1 CONCEPTS AND THEIR MUTUAL INTERRELATION 2.1.1 International Classification of Inlpail'lnents, Disabilities and Handicaps The classical medical model of disease is concerned with the etiology, pathology, manifestations and prognosis of disease. Most medical research focuses on one or more of these foUl' subjects. The International Classification of Disease (ICD) is also based on the pathway: etiology --> pathology --> manifestation (= symptoms and signs). [ In epidemiology research is concerned with the occurrence of disease, and with the determi nants of its distribution, such as risk factors and prognostic factors. The ultimate goal of most medical research is to prevent disease, 01' if this is not possible, to provide or develop optimal treatment once disease has developed. Much has been achieved in preventive medicine; in the developed countries infant and childhood mortality has decreased impressively since the begimling of this century, most major infectious diseases can be prevented or cured. As a result of improved health care premature death by cardiovascular disease can be prevented, and cancer-research made major progress in the knowledge of etiology and pathology and hence more and more oncologic diseases can be successfully treated. A consequence of this vast improvement of medical knowledge is that life-expectancy has been increased by tenths of years since 1900. More people reach old or even very old age. However, this has its drawbacks as well: increasingly more people reach old age 2 with chronic, incurable disease or with major disabilities.