This study estimated the incidence of acute physical disability related to musculoskeletal disorders in elderly patients using data from a primary care registry in Madrid, Spain. The registry identified 147 new cases of acute physical disability in 106 elderly patients over one year. The estimated annual incidence was 331 cases per 10,000 person-years. The incidence was higher in women (344 cases) than men (207 cases). Most cases involved moderate to high levels of physical disability, pain, and depression. This study provides valuable data on the magnitude of musculoskeletal disability in the elderly population.
2. onset physical disability should be a key element in being
able to offer them different proven interventions (8–11).
The purpose of this study was to estimate the incidence
of musculoskeletal physical disability in community-
dwelling people age Ն65 years, as the first part of a col-
laborative project between primary and specialized care
that was inspired by our former work in temporary work
disability (12).
PATIENTS AND METHODS
An internet-based primary care registry was established
from October 1, 2005 to September 31, 2006.
Setting. In Madrid (Spain) the public health system cov-
ers approximately 90% of the population, divided into 11
health areas. Each area is organized into a certain number
of primary health care centers attended by general practi-
tioners (GPs) around a referral hospital. Each GP is in
charge of a finite and limited population area defined by
the number of health cards assigned.
Study population. The registry was established in
Madrid’s Health Area 7, integrated by 16 primary health
care centers with a total of 319 GPs and a tertiary hospital
(Hospital Clı´nico San Carlos, study unit coordinator). This
health area covers a population of 635,220 inhabitants of
all socioeconomic backgrounds. Before the beginning of
the study, the coordinators explained the project in all
health care centers. Only centers with a significant propor-
tion of interested GPs were included in the population
area for the registry. Therefore, the area was that of all
non-institutionalized residents in Madrid’s Health Area 7,
who were age Ն65 years during the study period, and
whose health card was assigned to the participating GPs.
Case definition. A case was defined as a recent onset of
physical disability episode in an elderly person, which
was called an acute physical disability in the elderly
(APDE; see Appendix A for members of the APDE Group).
A subject had to be age Ն65 years, and was classified as
having an APDE episode when a moderate mobility alter-
ation was detected by the GPs, i.e., a progression to the
fourth level or higher in his/her level of disability accord-
ing to the Rosser’s Classification System (13) in the last 3
months (Table 1).
The episode had to be related to MSD, according to the
GP, and include general syndromes as follows: “weakness
and weariness,” “pain or stiffness in peripheral joints,”
“axial pain or stiffness,” “fear of falls,” “mechanical pain
in the trunk, pelvis, or limbs,” “weakness in arms or legs,”
“falls or injuries without peripheral fractures,” “joint
swelling,” or “other syndromes compatible with musculo-
skeletal diseases.” The specific diagnoses presumably re-
lated to the APDE episode were also registered by the GPs.
Cases were excluded if the patient’s health card was not
assigned to a participating GP, mainly because they were
living in a temporary residency, or if they had undergone
an orthopedic procedure in the month prior to the begin-
ning of the APDE episode.
Other variables and data collection. As secondary vari-
ables, we registered sex, age, comorbidities, and distress
(pain and depression; as measured by the Rosser’s Classi-
fication System [13]) (Table 1), the GP that recruited the
patient, and health care center. For each APDE episode, we
recorded the identification date and the MSD cause.
A computerized system was developed to facilitate the
identification and registry of the APDE episodes. The sys-
tem, accessible from the GP consultation offices, facilitated
the communication of the GPs with the coordinators of the
study and was capable of identifying duplicates, assigning
codes, and generating working lists. All variables were
entered by the GPs.
Significance & Innovations
● Disability caused by musculoskeletal disorders is
primarily related to a decrease in mobility.
● Physical disability in the elderly is related in a
large proportion to musculoskeletal problems.
● Recent onset of physical disability in the elderly is
recoverable and therefore should be a target of
health systems.
Table 1. Rosser Classification System, used for the case
definition of APDE (recent-onset, musculoskeletal-related
disability)*
Level of
disability Description
1 No disability
2 Slight social disability
3 Severe social disability and slight physical
disability or decrease of mobility; slight
work impairment; homemakers can
perform house chores except for the
heavier ones
4 Work alternatives may be limited or
present work may be performed with
many limitations; elderly and
homemakers can only perform light
chores, but are able to go shopping;
moderate decrease of mobility
5 Unable to perform paid work or to
continue studying if student; elderly
stay at home or go out for short walks
accompanied; inability to go shopping;
homemakers can only perform a few
chores; severe decrease of mobility
6 Confined to a chair or a wheelchair; only
able to walk at home with an aid;
almost dependent
7 In bed
8 Unconscious
* Grades of distress for each level are A ϭ none, B ϭ slight, C ϭ
high, and D ϭ very high. APDE ϭ acute physical disability in the
elderly.
90 Jover et al
3. Procedures and quality control. The study was coordi-
nated by the Rheumatology Department of the Hospital
Clı´nico San Carlos with the help of the Research Unit of
the Spanish Foundation of Rheumatology. The participat-
ing GPs were instructed and trained on the identification
of APDE cases during their routine practice, based on
complex fictitious cases. All of them had entered a pilot
study to check feasibility and difficulty. Additionally, pe-
riodic meetings were held at the health care centers to
maintain awareness of the project.
GPs signed an agreement to comply with the declaration
of Helsinki. Patients gave their verbal consent to be in-
cluded in the registry. The study protocol was approved by
the Hospital Clı´nico Research Ethics Committee.
Statistical analysis. Given that the incidence of recent-
onset musculoskeletal disability is unknown, we based the
sample size predetermination on indirect data. Approxi-
mately 11.8% of those age Ն65 years (20.7% of the general
population) are physically disabled due to musculoskeletal-
related disease, according to the 1999 National Disability
Survey (4). Our hypothesis was that one-third of the phys-
ical disability processes were of a recent onset; therefore,
we required at least 8,610 persons to estimate an incidence
between 3.6–4.4% with a relative error of 10% and a 95%
confidence interval (95% CI). Each GP treats an average of
343 different patients age Ն65 years annually; therefore,
we targeted to include at least 25 GPs.
The 1-year cumulative incidence rate (IR) of APDE epi-
sodes per 10,000 person-years was estimated with 95% CIs
from the number of new cases occurring in the population
covered by the participating GPs, using direct standardiza-
tion. The population denominators were the total popula-
tion assigned to the health areas of the participating GPs
during the study period. The estimate was then extrapo-
lated to the entire Health Area 7.
RESULTS
At the end of the inclusion period, 8 primary health care
centers (50% of the total in Health Area 7) and 23 GPs (7%
of the total GPs in Health Area 7) were finally evaluated.
The data from the rest of the primary health care centers
and GPs were not used for the estimation of the IR due to
protocol infringements in the recruitment case (i.e., sur-
gery in the preceding month or longer than 3 months with
the same level of disability), absence of a reliable denom-
inator by GP, or because they had entered the study after
half of the recruitment period had elapsed. The population
covered by participating GPs during the recruitment pe-
riod was 4,434 subjects age Ն65 years. From October 1,
2005 to September 31, 2006, 147 cases of APDE were
identified in 106 incident patients. The IR of APDE epi-
sodes was estimated in 331 cases per 10,000 person-years
(95% CI 280–389) and the IR of patients with a first APDE
episode was 239 (95% CI 196–288). APDE episodes were
higher in women (344 cases; 95% CI 279–423) than in
men (207 cases; 95% CI 127–338), although this was not
statistically significant. In our health area, we might expect
as many as 2,485 new APDE episodes annually. The esti-
mated incidence did not vary largely among GPs.
Table 2 shows the characteristics of patients with APDE.
Most of them were women in their 70s. The main general
syndromes associated with the APDE episodes were “pain
or stiffness in peripheral joints,” followed by “mechanical
pain in the trunk, pelvis or extremities,” and “axial pain or
stiffness.” GPs could enter Ͼ1 syndrome per case; in fact,
80% of the APDE episodes were related to Ͼ1 syndrome
and the average number of syndromes per patient was 3.
More than half the patients had some comorbidities, and
only 3 patients (3%) had none at all. The most frequent
were hypertension (77%), dyslipidemia (57%), gastro-
esophageal reflux (28%), obesity (24%), depression (23%),
and venous insufficiency (21%). Additional comorbidities
included diabetes mellitus (17%), fractures (14%; 50%
were vertebral fractures), chronic obstructive pulmonary
disease (10%), cerebrovascular disease (4%), cardiovascu-
lar disease (4%), heart failure (4%), chronic renal failure
(3%), and cancer (3%). The prevalence of other comorbidi-
ties was Ͻ2%.
All patients had at least 1 previous musculoskeletal
diagnosis: 98% osteoarthritis, 40% tendonitis, 20% sciat-
ica, 8% inflammatory diseases (mainly rheumatoid arthri-
tis or rheumatic polymyalgia), 6% orthopedic prostheses,
and 4% gouty arthritis. All patients showed moderate to
high levels of physical disability at the time of the APDE
episode, with a median Rosser disability level of 5 (pa-
tients were unable to leave home on their own, reflecting a
severe decrease in mobility). Moreover, 50% of the pa-
tients reported high or very high levels of pain in any
musculoskeletal location, and 35% reported severe de-
pression.
Table 2. Sociodemographic, clinical, and disability
characteristics of the 106 APDE patients*
Variable Value
Age, mean Ϯ SD years 77.5 Ϯ 7.4
Women 89 (85)
Major syndrome causing the disability
episode
Pain or stiffness in peripheral joints 22 (21)
Mechanical pain in the trunk,
pelvis, or extremities
21 (21)
Axial pain or stiffness 17 (16)
Weakness and weariness 12 (12)
Fear of falls 9 (8)
Falls or injuries without peripheral
fractures
8 (7)
Weakness in arms or legs 7 (7)
Joint swelling 6 (6)
Other reasons compatible with
musculoskeletal diseases
1 (1)
Charlson Comorbidity Index,
mean (range)
5.3 (0–8)
Rosser level, mean Ϯ SD 5 Ϯ 0.7
Disabled according to Rosser level
Rosser level 4 23 (22)
Rosser level 5 63 (60)
Rosser level 6 12 (12)
Rosser level 7 6 (6)
* Values are the number (percentage) unless indicated otherwise.
APDE ϭ acute physical disability in the elderly.
Musculoskeletal-Related Acute Physical Disability in the Elderly 91
4. DISCUSSION
In this study we have estimated the incidence of recent-
onset physical disability related to musculoskeletal disor-
ders in community-dwelling elderly. Using a pragmatic
system, new episodes of physical disability were identi-
fied in primary care practice, showing an incidence of 311
cases per 10,000 person-years in subjects age Ն65 years.
Therefore, in our health area, the annual amount of new
episodes of musculoskeletal physical disability in the pop-
ulation age Ն65 years seeking assistance in primary care
would be approximately 2,500. This estimation supposes a
big challenge for our health area, especially if we take into
account the inherent complexity of treating elderly pa-
tients with acute mobility restriction.
Our area is representative of a working and middle class
urban area in Spain, and our data would be applicable,
with the adequate corrections, to other similar settings. In
fact, in the population with an average age of 75 years,
especially in Spain, there are many more women than
men. The men usually die earlier and those who survive
are fit, while women live longer but with higher degrees of
disability and dependence (14). Also, these results are in
accordance with data from population studies (15). MSDs
are more frequent in women than in men, as well as
disability. It would be striking if we had seen differences
between GPs, and this was not the case.
Nevertheless, our estimates might be influenced by the
case definition, given that disability is a broad term with
different dimensions. Our study defined disability as a
deterioration in the functional level according to Rosser’s
Classification System (13), which is simpler than other
definitions of disability (16–19), is in line with the Global
Burden of Disease studies (20), and is applicable for dif-
ferent diseases and subjects’ ages. The Rosser system (21)
classifies function and mobility in 8 different levels, and
we determined the fourth level as the cut point, mostly
because it reflects well when physical disability, in addi-
tion to an individual health problem, starts to be a societal
challenge. When we compared other incidence studies,
our estimations were lower (16,22). In the study by Gill
et al (16,22), restricted activity was identified by monthly
calls, but included all causes of disability and was directed
to a previously selected, high-risk population. In the study
by da Silva et al (16,22), where a higher IR of disability was
found in women (although the sample was representative),
restricted activity was based on the modified Katz Index,
included all causes of disability, and was identified by 1
retrospective interview.
Apart from the different methodologies employed, our
inferior estimates might be also explained by 2 facts. The
first is that elderly people with health problems often do
not seek medical attention (16), and the second is that 10%
of the population in Madrid is covered by private insur-
ance (23) and such patients may not have been captured in
our study. The true incidence might be higher, as GPs are
overloaded and many times they are not able to detect new
APDEs.
With our system, we were able to identify a number of
patients ranging from moderate to severe levels of disabil-
ity. However, the levels of disability detected were high or
very high (either unable to go out of their home, needing
help to walk at home, or confined to bed) in Ͼ75% of the
new cases, suggesting that our system was useful to detect
the more serious cases of acute disability, but could lack
the sensitivity to detect the probably more frequent, less
severe situations.
Our patients were mostly women in their late 70s,
with axial and peripheral joint pain and stiffness. The
co-occurrence of different causes of disability in more than
two-thirds of the cases supported our decision of using
general syndromes in the case definition, which allowed
for an easy definition of the cases, even if some of them
could be related to other nonmusculoskeletal problems.
The specific diagnoses by GPs were mostly axial and pe-
ripheral osteoarthritis, followed by soft tissue problems
and inflammatory diseases, as expected (2,8,16,24,25). The
presence of a high Charlson index, a high level of pain, and
associated MSD comorbidities reflects the spectrum of the
more prevalent diseases at this age (26) and gives a clear
idea of the complex management needed to improve the
situation.
The limitations of our study are the difficult definition of
disability used, that GPs needed training, and the under-
powered results, although the CIs were sufficiently pre-
cise. However, given the absence of previous data and the
relevance of the problem, our study can be considered a
starting point in the resolution of MSDs in the elderly.
In conclusion, the findings of our study help to under-
stand the incidence and the etiology of the most common
cause of physical disability in the elderly, which is an
important issue given the increasing number of persons
age Ն65 years. Our findings are also a first step to under-
standing and palliating the individual and the societal
burden of MSDs. Moreover, the establishment of a routine
practice for the identification of recent-onset physical dis-
ability in the elderly allowed us to evaluate an early inter-
vention program for the recovery of cases in terms of
functioning, mobility, and independence.
ACKNOWLEDGMENTS
The authors are grateful to the staff of the Department of
Rheumatology of Hospital Clı´nico San Carlos, especially to
Angeles Lo´pez de Benito for support and help during the
study, as well as to all the coordinators of the primary care
teams in the study centers.
AUTHOR CONTRIBUTIONS
All authors were involved in drafting the article or revising it
critically for important intellectual content, and all authors ap-
proved the final version to be submitted for publication. Dr. Leon
had full access to all of the data in the study and takes responsi-
bility for the integrity of the data and the accuracy of the data
analysis.
Study conception and design. Jover, Lajas, Leon, Carmona, Serra,
Reoyo, Abasolo.
Acquisition of data. Jover, Lajas, Leon, Carmona, Serra, Abasolo.
Analysis and interpretation of data. Jover, Lajas, Leon, Carmona,
Serra, Rodriguez-Rodriguez, Abasolo.
92 Jover et al
5. REFERENCES
1. Hunter DJ, Reddy KS. Noncommunicable diseases. N Engl
J Med 2013;369:1336–43.
2. Badley EM, Rasooly I, Webster GK. Relative importance of
musculoskeletal disorders as a cause of chronic health prob-
lems, disability, and health care utilization: findings from the
1990 Ontario Health Survey. J Rheumatol 1994;21:505–14.
3. Blanco M, Candelas G, Molina M, Banares A, Jover J. Charac-
teristics of temporary work disability related to musculoskel-
etal disorders in the autonomous community of Madrid dur-
ing one year. Rev Esp Reumatol 2000;27:48–53.
4. National Institute for Statistics (INE). Survey of disability,
deficiencies, and mental health status. 1999. URL: http://
www.ine.es/revistas/cipraine/1009.pdf.
5. Hardy SE, Gill TM. Recovery from disability among
community-dwelling older persons. JAMA 2004;291:1596–
602.
6. Hardy SE, Gill TM. Factors associated with recovery of inde-
pendence among newly disabled older persons. Arch Intern
Med 2005;165:106–12.
7. Gill TM, Robison JT, Tinetti ME. Difficulty and depen-
dence: two components of the disability continuum among
community-living older persons. Ann Intern Med 1998;128:
96–101.
8. Reid MC, Williams CS, Gill TM. The relationship between
psychological factors and disabling musculoskeletal pain in
community-dwelling older persons. J Am Geriatr Soc 2003;
51:1092–8.
9. Gill TM, Baker DI, Gottschalk M, Peduzzi PN, Allore H, Byers
A. A program to prevent functional decline in physically frail,
elderly persons who live at home. N Engl J Med 2002;347:
1068–74.
10. Gill TM, Allore H, Guo Z. Restricted activity and functional
decline among community-living older persons. Arch Intern
Med 2003;163:1317–22.
11. Van Lankveld W, Franssen M, van Kessel M, van de Putte L.
Gerontorheumatologic outpatient service. Arthritis Rheum
2004;51:299–301.
12. Abasolo L, Blanco M, Bachiller J, Candelas G, Collado P, Lajas
C, et al. A health system program to reduce work disability
related to musculoskeletal disorders. Ann Intern Med 2005;
143:404–14.
13. Rosser RM, Watts VC. The measurement of hospital output.
Int J Epidemiol 1972;1:361–8.
14. Villarejo PC, Garcia AA. Estados de salud. Capı´tulo 2. Las
personas Mayores en Espan˜a. Informe. 2008. URL: http://www.
espaciomayores.es/InterPresent1/groups/imserso/documents/
binario/04-informe2008-vol1-cap2.pdf.
15. Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati
M, et al. Years lived with disability (YLDs) for 1160 sequelae
of 289 diseases and injuries 1990-2010: a systematic analysis
for the Global Burden of Disease Study 2010. Lancet 2012;
380:2163–96.
16. Gill T, Desai M, Gahbauer E, Holford T, Williams C. Restricted
activity among community-living older persons: incidence,
precipitants and health care utilization. Ann Intern Med
2001;135:313–21.
17. Wen X. The definition and prevalence of physical disability
in Australia. Canberra: AIHW; 1999.
18. Kosorok MR, Omenn GS, Diehr P, Koepsell TD, Patrick DL.
Restricted activity days among older adults. Am J Public
Health 1992;82:1263–7.
19. Scholes D, LaCroix A, Wagner E, Grothaus L, Hecht J. Track-
ing progress toward national health objectives in the elderly:
what do restricted activity days signify? Am J Public Health
1991;81:485–8.
20. Salomon JA, Vos T, Hogan DR, Gagnon M, Naghavi M,
Mokdad A, et al. Common values in assessing health out-
comes from disease and injury: disability weights measure-
ment study for the Global Burden of Disease Study 2010.
Lancet 2012;380:2129–43.
21. Ayis SA, Bowling A, Gooberman-Hill R, Ebrahim S. The effect
of definitions of activities of daily living on estimates of
changing ability among older people. Int J Rehabil Res 2007;
30:39–46.
22. Da Silva T, Corona LP, Nunes DP, Santos JL, Duarte YA,
Lebrao ML. Gender differences in incidence and determinants
of disability in activities of daily living among elderly
individuals: SABE study. Arch Gerontol Geriatr 2012;55:
431–7.
23. Fuste J, Seculi E, Brugulat P, Medina A, Junca S. Public
healthcare coverage versus double healthcare coverage: what
are the differences? Gac Sanit 2005;19:15–21.
24. Leveille SG, Ling S, Hochberg MC, Resnick HE, Bandeen-
Roche KJ, Won A, et al. Widespread musculoskeletal pain and
the progression of disability in older disabled women. Ann
Intern Med 2001;135:1038–46.
25. Scudds RJ, McD Robertson J. Empirical evidence of the asso-
ciation between the presence of musculoskeletal pain and
physical disability in community-dwelling senior citizens.
Pain 1998;75:229–35.
26. Carmona L, Ballina J, Gabriel R, Laffon A. The burden of
musculoskeletal diseases in the general population of Spain:
results from a national survey. Ann Rheum Dis 2001;60:
1040–5.
APPENDIX A: THE APDE GROUP
Members of the APDE Group are as follows (in alphabetical
order): Aba´solo L., Aguilera P., Arnalte M., Barrios E., Be´jar J. M.,
Bermejo J., Cabrera R., Carmona L., Carravilla J. R., Carren˜o P.,
Co´ndor M. L., Del Castillo M., Del Valle I., Estevez J. C., Gil I.,
Heras M. G., Jover J. A., Lajas C. J., Leo´n L., Linares L., Martı´n R.,
Melendro I., Mun˜oz R., Pe´rez S., Polo E., Pujol P., Reoyo A., Seijas
M. J., Serra J. A.
Musculoskeletal-Related Acute Physical Disability in the Elderly 93
![onset physical disability should be a key element in being
able to offer them different proven interventions (8–11).
The purpose of this study was to estimate the incidence
of musculoskeletal physical disability in community-
dwelling people age Ն65 years, as the first part of a col-
laborative project between primary and specialized care
that was inspired by our former work in temporary work
disability (12).
PATIENTS AND METHODS
An internet-based primary care registry was established
from October 1, 2005 to September 31, 2006.
Setting. In Madrid (Spain) the public health system cov-
ers approximately 90% of the population, divided into 11
health areas. Each area is organized into a certain number
of primary health care centers attended by general practi-
tioners (GPs) around a referral hospital. Each GP is in
charge of a finite and limited population area defined by
the number of health cards assigned.
Study population. The registry was established in
Madrid’s Health Area 7, integrated by 16 primary health
care centers with a total of 319 GPs and a tertiary hospital
(Hospital Clı´nico San Carlos, study unit coordinator). This
health area covers a population of 635,220 inhabitants of
all socioeconomic backgrounds. Before the beginning of
the study, the coordinators explained the project in all
health care centers. Only centers with a significant propor-
tion of interested GPs were included in the population
area for the registry. Therefore, the area was that of all
non-institutionalized residents in Madrid’s Health Area 7,
who were age Ն65 years during the study period, and
whose health card was assigned to the participating GPs.
Case definition. A case was defined as a recent onset of
physical disability episode in an elderly person, which
was called an acute physical disability in the elderly
(APDE; see Appendix A for members of the APDE Group).
A subject had to be age Ն65 years, and was classified as
having an APDE episode when a moderate mobility alter-
ation was detected by the GPs, i.e., a progression to the
fourth level or higher in his/her level of disability accord-
ing to the Rosser’s Classification System (13) in the last 3
months (Table 1).
The episode had to be related to MSD, according to the
GP, and include general syndromes as follows: “weakness
and weariness,” “pain or stiffness in peripheral joints,”
“axial pain or stiffness,” “fear of falls,” “mechanical pain
in the trunk, pelvis, or limbs,” “weakness in arms or legs,”
“falls or injuries without peripheral fractures,” “joint
swelling,” or “other syndromes compatible with musculo-
skeletal diseases.” The specific diagnoses presumably re-
lated to the APDE episode were also registered by the GPs.
Cases were excluded if the patient’s health card was not
assigned to a participating GP, mainly because they were
living in a temporary residency, or if they had undergone
an orthopedic procedure in the month prior to the begin-
ning of the APDE episode.
Other variables and data collection. As secondary vari-
ables, we registered sex, age, comorbidities, and distress
(pain and depression; as measured by the Rosser’s Classi-
fication System [13]) (Table 1), the GP that recruited the
patient, and health care center. For each APDE episode, we
recorded the identification date and the MSD cause.
A computerized system was developed to facilitate the
identification and registry of the APDE episodes. The sys-
tem, accessible from the GP consultation offices, facilitated
the communication of the GPs with the coordinators of the
study and was capable of identifying duplicates, assigning
codes, and generating working lists. All variables were
entered by the GPs.
Significance & Innovations
● Disability caused by musculoskeletal disorders is
primarily related to a decrease in mobility.
● Physical disability in the elderly is related in a
large proportion to musculoskeletal problems.
● Recent onset of physical disability in the elderly is
recoverable and therefore should be a target of
health systems.
Table 1. Rosser Classification System, used for the case
definition of APDE (recent-onset, musculoskeletal-related
disability)*
Level of
disability Description
1 No disability
2 Slight social disability
3 Severe social disability and slight physical
disability or decrease of mobility; slight
work impairment; homemakers can
perform house chores except for the
heavier ones
4 Work alternatives may be limited or
present work may be performed with
many limitations; elderly and
homemakers can only perform light
chores, but are able to go shopping;
moderate decrease of mobility
5 Unable to perform paid work or to
continue studying if student; elderly
stay at home or go out for short walks
accompanied; inability to go shopping;
homemakers can only perform a few
chores; severe decrease of mobility
6 Confined to a chair or a wheelchair; only
able to walk at home with an aid;
almost dependent
7 In bed
8 Unconscious
* Grades of distress for each level are A ϭ none, B ϭ slight, C ϭ
high, and D ϭ very high. APDE ϭ acute physical disability in the
elderly.
90 Jover et al](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)