Tuesday, October 26, 2010

Life Space: Living Well Despite Disability

Geriatric Medicine is obsessed with functional status and disability. Much of the practice of Geriatrics revolves around the prevention or rehabilitation of functional status problems.

But what is functional status? Ironically, despite the importance of functional status to Geriatrics, defining what functional status is, or how it should be assessed is not so obvious. In practice, most functional status evaluations focus on assessing whether or not patients can do specific tasks important to day to day life. For example, can you do basic activities of daily living such as take a bath or shower, get dressed, or walk across a room with assistance? Can you do housework, manage your finances, and manage your medicines?

But there is increasing interest in more holistic views of functional status. These views focus not just on tasks you can or can't do, but on how well you live despite of functional problems. One of the most interesting of these new ways of thinking about functional status is Life Space. Life Space considers the size of the person's world. Are you confined to your home, or you able to get out to town, or even out of town?

Consider the following example:

Older person A is independent in all basic activities of daily living and can walk moderate distances. But she is depressed and has limited social support and seldom gets out of her residence. Older person B depends on the help of others for basic activities of daily life such as bathing. She can only walk a few steps without assistance. But she has a supportive family that helps with basic activities. With her motorized scooter, she makes it to church and her weekly bridge game. Her family helps help her get out of town on their family vacations.

Who is more disabled? Classical measures of functional status would say patient B. But a Life Space approach recognizes Patient B as doing much better than patient A.

A recent study in the Journal of the American Geriatrics Society from Dr. Patricia Boyle provides important evidence supporting the assessment of life space by showing that it is strongly associated with mortality. They followed over 1400 elders for up to 8 years. Those who had wide life spaces had much better survival than those who had a constricted life space. For example, among those able to get out beyond their home town, 5 year mortality was about 13%. However, among those restricted to the confines of their home, 5 year mortality was about 24%. Life space was associated with mortality even after accounting for classic measures of disability such as difficulty with basic activities of daily living. This means that life space is telling us something important, beyond the tasks an older person can or can not do.

We need more focus on functional status measures that tells us how well our patients live, rather than simply what tasks than can or can not do. We need to incorporate more measures of life space into Geriatric practice and research. I wonder if more attention to these measures will improve practice by helping us think not just about an elder's degree of disability, but how we palliate their disability by helping them live well despite disability.

by: [Ken Covinsky]

4 comments:

Mike Steinman said...

To amplify Ken's thoughtful comments on Life Space, it may be useful to think about this concept through the "disablement process" model articulted by Verbrugge and Jette in a seminal article in the 1990s. In that model, "functional limitations" (such as difficulty walking) can lead to "disability", defined as inability to independently complete tasks important to social functioning (e.g., working, participating in community activities, etc.). A key idea from that model is that whether functional limitations lead to disability is mediated largely by one's own personal resources as well as environmental resources. For example, a person with difficulty walking who has a strong motivation to succeed, good social supports, and an environment with elevator access and limited stairs can thrive in their social roles. In contrats, someone who is disspirited, who has few external supports, and lives in a challenging physical environment is likely to end up with much greater disability. One can imagine how the presence or absence of these internal and external supports could impact many other important outcomes as well.

Cyndi, RN, OCN, PCRN said...

I hadn't heard about the Life Space approach before--very interesting!

This shows how quality of life is different for each person. Also has implications for Advance Care Planning for healthy individuals. What you think would be unacceptable when you are healthy might be different once you are "disabled"...that's why the discussion needs to be ongoing and evolving...

Eric Widera said...

Do online sites expand ones social roles and life space even if they may remain home bound?

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