Rev Saúde Pública 2011;45(4)

Eleonora d’OrsiI
Work, social support and
André Junqueira XavierII

Luiz Roberto RamosIII

leisure protect the elderly from
functional loss: EPIDOSO Study

ABSTRACT

OBJECTIVE: To identify risk factors for functional capacity loss in elderly

people.
METHODS: Epidoso (Epidemiology of the Elderly) cohort study with elderly
people living in São Paulo (Southeastern Brazil). A total of 326 participants in
the first interview (1991-1992) who were independent or had mild dependence
(one or two activities of daily living) were selected. Those who presented
functional loss in the second (1994-1995) or third interviews (1998-1999) were
compared to those who did not present it. The incidence of functional loss
was calculated according to sociodemographic variables, life habits, cognitive
status, morbidity, hospitalization, self-rated health, tooth loss, social support
and leisure activities. Crude and adjusted relative risks with 95% confidence
intervals were estimated through bivariate and multiple analyses with Poisson
regression. The criterion for the inclusion of the variables in the model was p
< 0.20 and for exclusion, p > 0.10.
RESULTS: The incidence of functional loss was 17.8% (13.6; 21.9). The risk
factors in the final model were: age group 70-74 years RR=1.9 (0.9;3.9); age
group 75-79 years RR=2.8 (1.4;5.5); age group 80 years or older RR=5.4
(3.0;9.6); score in the mini-mental state examination <24 RR=1.8 (1.1;2.9);
asthma RR=2.3 (1.3;3.9); hypertension RR=1.7 (1.1;2.6); and diabetes RR=1.7
(0.9;3.0). The protective factors were: paid work RR=0.3 (0.1;1.0); monthly
relationship with friends RR=0.5 (0.3;0.8); watching TV RR=0.5 (0.3;0.9);
and handcrafting RR=0.7 (0.4;1.0).
CONCLUSIONS: The prevention of functional loss should include adequate
control of chronic diseases, like hypertension, asthma and diabetes, as well
I
Programa de Pós-Graduação em Saúde as cognitive stimulation. Work, leisure and relationships with friends should
Coletiva, Universidade Federal de Santa
Catarina. Florianópolis, SC, Brasil be valued due to their protective effect.

II
Curso de Medicina. Universidade do Sul de DESCRIPTORS: Aged. Activities of Daily Living. Leisure Activities.
Santa Catarina. Palhoça, SC, Brasil
Social Support. Personal Autonomy. Socioeconomic Factors. Cohort
III
Departamento de Medicina Preventiva. Studies.
Universidade Federal de São Paulo. São
Paulo, SP, Brasil

Correspondence:
Eleonora d’Orsi INTRODUCTION
Departamento de Saúde Pública
Universidade Federal de Santa Catarina Functional capacity involves multiple factors such as autonomy, independence,
Campus Universitário Trindade
88037-404 Florianópolis, SC, Brasil cognition, financial and social support. In practice, professionals work with the
E-mail: [email protected] concept of capacity versus incapacity. Functional incapacity can be defined by
the degree of difficulty in performing activities of daily living (ADL).19 In the
Received: 9/11/2010
Approved: 2/6/2011
study called EPIDOSO (Epidemiology of the Elderly) and in others,7,16,17,18,19
functional capacity is measured through ADL scales. The questions approach
Article available from: www.scielo.br/rsp basic activities for body or personal maintenance (PADL), like bathing, dressing,
2 Work, social support and leisure against functional loss d’Orsi E et al

going to the toilet in time, getting in/out of bed, getting conducted in 1991-1992, the second in 1994-1995, the
up from a chair, feeding oneself, grooming, cutting third in 1998-1999, and the fourth in 2000-2001.
toenails, climbing a flight of stairs and walking on a
level surface; and activities to live independently in The home interviews used the Brazilian
the community or instrumental activities (IADL), like Multidimensional Function Assessment Questionnaire
preparing meals, shopping, taking a bus, walking to a (BOMFAQ), adapted from the questionnaire Older
place near home, taking medications on the right time Americans Resources and Services (OARS), which
and cleaning the house. has been utilized in cross-sectional studies with elderly
people living in São Paulo.17 The instrument collected
Risk factors for mortality in elderly people are well information on socioeconomic and demographic
established in the literature. International and national characteristics, informal support (not provided by the
studies identify functional incapacity as one of the main government or specialized institutions), independence
predictive factors of mortality in the elderly,4,6,12,16 and level in the ADL, chronic diseases, mental health,
its effect is more important than cognitive status.6, 16
cognition, and self-rated health. The BOMFAQ func-
In a study with people aged 85 years or older, func-
tional capacity questionnaire includes eight questions
tional incapacity was a better predictor of mortality
related to the ADL: getting in/out of bed, eating,
in elderly individuals than pathologies.4 There is a
grooming, walking on a level surface, bathing, dressing,
well-established link between functional incapacity
going to the toilet in time, and climbing a flight of stairs;
and mortality. What would be the preceding link, to
prevent incapacity? and seven questions related to IADL: taking medica-
tions on time, walking near home, shopping, preparing
Verbrugge & Jette23 (1994) propose a theoretical model meals, cutting toenails, taking a collective means of
of the process of becoming incapable, considering three transport, and cleaning the house, totaling 15 questions.
aspects: (i) predisposing factors (sociodemographic
characteristics); (ii) intra-individual factors (lifestyle, The participants in the first interview (1991-1992) who
morbidities, self-rated health, behavior changes, were independent or had mild dependence (1 or 2 ADL/
manners of dealing with difficulties, with diseases IADL) were selected. Functional loss was defined as
and with modifications in activities that can affect the dependence in seven or more ADL/IADL. Those who
incapacity process); and (iii) extra-individual factors presented functional loss in the second (1994-1995)
(interventions of the health and rehabilitation services, or third interviews (1998-1999) were identified and
use of medicines, external supports and physical and compared to those who had not presented it up to
social environment). that time.

National cross-sectional studies have examined the The dependent variable was functional loss in the
possible factors associated with functional inca- second or third interviews. The independent variables
pacity.1,3,5,7,11,14,19,20 The identification of these factors tested were: sociodemographic (sex, age group, marital
can subsidize health interventions to increase the status, race/color, level of schooling, paid work), life
survival time free of disabilities. This paper aimed habits (physical and sexual activity), probable cogni-
to identify risk factors for functional capacity loss in tive deficit (score in the mini-mental state examination
elderly people. <24), self-reported morbidity (hypertension, asthma,
diabetes, cerebrovascular accident, urinary incon-
METHODS tinence, insomnia, cataract), falls, hospitalization,
tooth loss, self-rated health, social support (monthly
The research used data from a population-based cohort relationship with friends, neighbors, relatives, having a
study called EPIDOSO, carried out with elderly indi- confidant friend), leisure activities (trips, handcrafting,
viduals living in the community, in a residential area games, reading).
of the municipality of São Paulo (Southeastern Brazil),
promoted by the Centro de Estudos de Envelhecimento Crude and adjusted relative risks were calculated with
(Center for Aging Studies) of Escola Paulista de respective 95% confidence intervals, by bivariate and
Medicina of Universidade Federal de São Paulo. multiple analyses with Poisson regression (robust
The participants were followed up during ten years, variance). The criterion for inclusion of the variables
in four waves of home inquiries. Of the 55 districts of in the model was p < 0.20 and for exclusion, p > 0.10.
the municipality of São Paulo, the Saúde district was The analysis was performed in the Program STATA
selected. The participants were selected by means of version 10.0.
a census that was performed in the 52 census tracts
of Saúde, which identified the inhabitants who were The study was approved by the Ethics Research
older than 65 years as eligible for the study,17 totaling Committee of Universidade Federal de São Paulo
1,667 interviewed elderly people. The first inquiry was (Process no. 0593.03) on 5/30/2003.
Rev Saúde Pública 2011;45(4) 3

RESULTS The protective factors were: participating in parlor

games, watching TV and handcrafting. Sexual activity
Among the elderly of the first interview (n = 1667), 972 was a protection factor, as well as maintenance of paid
were identified as independent or with mild dependence. work (Table 3).
Of these, 326 were interviewed in the second and/or
third interviews. There were 646 losses (127 deaths, Elderly individuals who reported monthly relationship
221 changes of address and 298 refusals). There were with friends and having a confidant friend presented
no significant differences between the interviewees and lower risk of functional loss (Table 4).
the follow-up losses according to sex, level of schooling,
After adjustment by multiple analysis, age between 75
presence of paid work, self-rated health or cognitive
and 79 years or 80 years and more, probable cognitive
impairment. There was a slightly higher percentage of
deficit, arterial hypertension, asthma and diabetes were
individuals older than 80 years among the losses (14.4%)
independent risk factors for functional loss in the final
than among the interviewees (10.4%), which is a statis-
model. Paid work, monthly relationship with friends,
tically significant difference (p = 0.03). The average watching TV and handcrafting were protective factors
income of the losses was higher than that of the inter- (Table 5).
viewees (p = 0.03). The incidence of functional loss was
17.8% (95%CI 13.6;21.9), 58 cases in 326 participants.
DISCUSSION
Among the sociodemographic variables, the bivariate
analysis presented higher risk of functional loss for Increase in age, cognitive impairment, arterial hyperten-
individuals older than 75 years (Table 1). sion, asthma and diabetes were risk factors for func-
tional loss. On the other hand, the maintenance of paid
Higher risk was observed for elderly individuals with work, monthly relationship with friends, watching TV
poorer self-rated health, asthma, arterial hypertension, and handcrafting were independent protection factors.
diabetes and urinary incontinence. Cognitive impair-
ment (MMSE < 24) also presented association with Self-rated health and sexual life are important predictors
functional loss (Table 2). of functional incapacity, although they did not remain in

Table 1. Sociodemographic factors associated with functional loss in elderly individuals. São Paulo, Southeastern Brazil,
1991-1999.
Variable n % Crude RR 95%CI p*
Sex
Female 202 17.8 1
Male 124 17.2 0.99 0.61;1.61 0.985
Age group (years)
65 to 69 136 8.8 1
70 to 74 84 14.3 1.61 0.76;3.44 0.210
75 to 79 72 19.5 2.20 1.07;4.51 0.031
80 and older 34 58.8 6.67 3.62;12.26 < 0.001
Level of schooling
High School/Higher Education 104 17.3 1
Junior High School 57 17.5 1.01 0.50;2.04 0.970
Elementary School 106 16.0 0.92 0.50;1.69 0.805
Illiterate/reads/writes 59 22.0 1.27 0.67;2.41 0.459
Marital status
Single 30 6.7 1
Married 195 16.9 2.53 0.64;10.05 0.185
Widow/widower 86 24.4 3.66 0.91;14.73 0.068
Divorced 15 13.3 1.99 0.31;12.87 0.466
Race/color
White 294 18.4 1
Mixed/Black 15 6.7 0.36 0.05;2.45 0.299
Yellow 14 14.3 0.77 0.21;2.87 0.706
* Poisson Regression
4 Work, social support and leisure against functional loss d’Orsi E et al

Table 2. Intra-individual factors (health, morbidities, cognition) Table 3. Intra-individual factors (lifestyle) associated with
associated with functional loss in elderly individuals. São functional loss in elderly individuals. São Paulo, Southeastern
Paulo, Southeastern Brazil, 1991-1999. Brazil, 1991-1999.
Crude Crude
Variable n % 95%CI p* Variable n % 95%CI p*
RR RR
Self-rated health Physical activity
Very good 77 9.1 1 No 226 19.5 1
Good 201 17.4 1.91 0.88;4.13 0.098 Yes 100 14.0 0.72 0.41;1.25 0.244
Poor/very Sexual activity
48 33.3 3.66 1.62;8.26 0.002
poor
No 200 22.5 1
Asthma
Yes 115 10.4 0.46 0.25;0.84 0.011
No 299 16.4 1
Paid work
Yes 27 33.3 2.03 1.12;3.67 0.019
Hypertension No 274 20.1 1

No 208 14.4 1 Yes 52 5.8 0.29 0.09;0.88 0.030

Yes 118 23.7 1.64 1.03;2.61 0.035 Travels

Diabetes No 80 22.5 1
No 297 16.5 1 Yes 243 16.0 0.71 0.43;1.17 0.184
Yes 29 31.0 1.88 1.03;3.43 0.039 Parlor games
Cerebrovascular accident No 259 20.1 1
No 319 17.6 1 Yes 66 9.1 0.45 0.20;1.00 0.053
Yes 7 28.6 1.62 0.49;5.38 0.425 Watches TV
Urinary incontinence No 29 31.0 1
No 283 15.9 1 Yes 296 16.6 0.53 0.29;0.97 0.040
Yes 43 30.2 1.90 1.12;3.22 0.017 Handcrafting
Insomnia
No 118 22.9 1
No 218 16.5 1
Yes 207 15.0 0.65 0.41;1.04 0.074
Yes 108 20.4 1.23 0.76;1.99 0.390
Reading
Cataract
No 86 21.0 1
No 264 19.3 1
Yes 239 16.7 0.79 0.48;1.31 0.380
Yes 62 11.3 0.58 0.27;1.22 0.155
* Poisson Regression
Tooth loss
No 79 12.7 1
Partial 88 18.2 1.43 0.69;2.98 0.331 There are consensus and particularities in the identifica-
Total 159 20.1 1.58 0.82;3.06 0.167 tion of factors associated with functional capacity loss,
Falls like the use of different functional and cognitive assess-
No 229 17.0 1 ment scales, which hinders the comparison between
Yes 97 19.6 1.15 0.70;1.88 0.580 studies. Studied variables may contain a subjectivity
Hospitalization component, like self-rated heath and self-reported and
non-diagnosed diseases.
No 308 17.5 1
Yes 18 22.2 1.26 0.51;3.11 0.605 Scale standardization to measure functional capacity
Cognitive status by means of the ADL is necessary to render the studies
Minimental in the area uniform.
270 13.3 1
≥24
Minimental Studies have reported association between increase in
56 39.3 2.94 1.88;4.60 <0.001 age and functional loss.1,3,5,7,11,14,19 Decrease in muscular
< 24
* Poisson Regression and bone mass, in basal metabolism and energy reserve,
with the consequent loss of the capacity to react against
stressors, accompany the increase in age and may lead
the final adjusted model. Depression, which is a preva- to the frailty syndrome, which exposes autonomous
lent morbidity among the elderly, can also generate elderly people to functional loss and dependence.
functional incapacity.10 This variable (depression) was The prevalence of frailty increases from the age of 65
accessed in the EPIDOSO study, but it was not utilized onwards and reduces survival within each age group.
due to the excess of missing values. Age and frailty became fuzzy, as they summarize
Rev Saúde Pública 2011;45(4) 5

Table 4. Extra-individual factors (social support) associated Table 5. Factors associated with functional loss in elderly
with functional loss in elderly individuals. São Paulo, individuals. São Paulo, Southeastern Brazil, 1991-1999.
Southeastern Brazil, 1991-1999. Adjusted
Variable 95% CI p*
Variable n % Crude RR 95%CI p* RR
Monthly relationship with relatives Age group (years)
No 28 21.4 1 65 to 69 1
Yes 298 17.5 0.81 0.38;1.72 0.592 70 to 74 1.94 0.96;3.91 0.066
Monthly relationship with neighbors 75 to 79 2.78 1.39;5.53 0.004
No 33 24.2 1 80 and older 5.39 3.02;9.60 <0.001
Yes 293 17.1 0.70 0.36;1.35 0.293 Cognitive status
Monthly relationship with friends Minimental ≥ 24 1
No 43 30.2 1 Minimental < 24 1.77 1.08;2.89 0.024
Yes 283 15.9 0.52 0.31;0.89 0.017 Hypertension

Confidant friend No 1

No 239 20.1 1 Yes 1.73 1.14;2.62 0.010

Yes 87 11.5 0.57 0.30;1.08 0.086 Asthma

* Poisson Regression No 1.00

Yes 2.30 1.32;3.98 0.003
Diabetes
multiple deficits in many domains.21 However, the No 1.00
frailty status can be modified, unlike age. Yes 1.68 0.94-3.00 0.081
Sectional design studies are limited to apprehend this Paid work
phenomenon. The national studies about functional No 1.00
capacity have cross-sectional designs that assess the Yes 0.34 0.11-1.02 0.056
prevalence and factors associated with incapacity. The Monthly relationship with friends
present study was the first one to assess functional loss No 1
in a longitudinal way, i.e., which factors determined
Yes 0.49 0.30;0.80 0.005
the functional capacity loss of elderly people. The
comparison with other studies should take method- Watches TV
ological differences into account. No 1
Yes 0.48 0.26;0.88 0.019
Based on the longitudinal view, the earliest functional Handcrafting
capacities that are lost are the most complex ones, as
No 1
they require an accurate and coordinated interaction
Yes 0.63 0.39;1.00 0.051
between several components of the individual. These
highly complex functions include from walking to * Poisson Regression
advanced cognitive processes, like executive functions
and divided attention. Youths and elderly individuals
In a review paper about functional incapacity among
can be seen as complex systems, but many functions
community elderly, the health conditions that were most
are approaching failure in the elderly;24 thus, small
frequently associated with functional decline were:
stressors present greater clinical meaning.
hypertension, cerebrovascular accident, diabetes and
Cognitive impairment has been associated with func- arthritis.22 Recent national studies have shown an asso-
tional loss and is considered one of the most important ciation between functional incapacity and hypertension
risk factors.8,13 Cognitive impairment frequently starts and diabetes.7 Hypertension is a highly prevalent condi-
with difficulties in accomplishing the IADL, like tion in the elderly that can be prevented, treated and
shopping, taking a bus, managing money. These are controlled. However, the adequate control of hyperten-
called executive functions and are lost in early.13,24 sion among treated adults and elderly people is low.15
The elderly who present difficulties in these functions
cease to accomplish them progressively because their Despite the vast literature on the benefits of diabetes
relatives are concerned about the mistakes they make control, Koro et al9 (2004) showed, in North-American
and assume their responsibilities, which aggravates population-based inquiries, that there was an increase
the dependence condition. Executive functions are in the prevalence of diabetes and a decline in glycemic
a fundamental aspect of cognition because they can control in this population from 1988 to 2000. The
compensate for functional loss and both together are high cumulative incidence of cognitive decline,
strong predictors of mortality.24 physical decline and geriatric syndromes among
6 Work, social support and leisure against functional loss d’Orsi E et al

diabetic elderly people indicates the need to focus the present study, it is possible to state that the social
more intensely on public health measures that reduce support deriving from the monthly relationship with
the burden of this disease. friends protects against functional loss, showing the
importance of social and affective relations, especially
Arif et al2 (2005) mention that asthma is common
friendship, for active aging.
among the elderly and that female sex, low socioeco-
nomic level, obesity, poor air quality and smoking are Leisure activities, like watching TV, that denote
associated with its gravity. People who suffer from interest in day-by-day life, and handcrafting, that
asthma rate their health status as medium or poor and demands ability and planning, may have a protective
state that their quality of life is compromised. effect through mechanisms that are similar to the labor
Studies show a protective effect of paid work or a risk activity, except that they do not necessarily involve
effect for functional incapacity in the retired elderly contact with other people. Possibly, these and other
when compared to those who continued working.19,20 activities, such as those involving learning, have a
The maintenance of paid work may have a protec- protective effect by mechanisms that involve cognitive
tive effect through social support mechanisms that stimulation and compensatory mechanisms of the social
are similar to those that explain the protective effect support network, which occurs in most leisure activities.
of the monthly relationship with friends. Interacting Again, social relations are identified as essential for the
with other people provides fundamental cooperation maintenance of functional capacity
relationships. The labor activity can also involve Among the limitations of this study, we can mention
competition mechanisms that are, to a certain extent, errors in the classification of the outcome due to self-
beneficial, as they imply daily challenges that keep the reported measure of functional capacity and losses
worker active and help in the maintenance of functional in the cohort follow-up. The absence of significant
capacity. Paid work is a hard executive function as it is differences between the interviewees and the follow-up
supervised and there is a level of competence involved. losses according to sex, level of schooling, presence of
A multicentric study in Finland, Holland and Spain paid work, self-rated health, or cognitive impairment
compared the prevalence, incidence and recovery of suggests that they were random losses that did not affect
incapacity among community elderly individuals and the validity of the results.
showed that social bonds (familial and non-familial)
To conclude, the prevention of functional loss should
protect against incapacity in aging.25 In Belo Horizonte,
include the adequate control of chronic diseases, like
Southeastern Brazil, monthly relationship with friends
hypertension, asthma and diabetes, and stimulus to
was found to have a protective association,7 like in
cognitive activity. Social interaction protects the elderly
São Paulo.19
from functional loss. Labor and leisure activities should
The majority of the cross-sectional studies that found an be valued throughout life, especially in more advanced
association between family and/or friendship relation- ages, as well as relationship with friends, with special
ship and functional capacity have questioned whether attention to the social, cultural, biological and medica-
such relationships would be the causes or consequences mental factors that hinder or impair the maintenance of
of functional capacity. Given the longitudinal design of these activities by the elderly.

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Research financed by Fundação de Amparo à Pesquisa do Estado de São Paulo (Process no.: 90/3935-7).
The authors declare no conflicts of interest.