Volume 70, Issue 10 p. 2884-2894
Clinical Investigation

A comprehensive prognostic tool for older adults: Predicting death, ADL disability, and walking disability simultaneously

Alexandra K. Lee PhD, MSPH

Corresponding Author

Alexandra K. Lee PhD, MSPH

Division of Geriatrics, Department of Medicine, UCSF, San Francisco, California, USA

Health Service Research and Development, San Francisco Veterans Affairs Healthcare System, San Francisco, California, USA

Correspondence

Alexandra K. Lee, Division of Geriatrics, Department of Medicine, UCSF, 4150 Clement St, VA181G, San Francisco, CA 94121, USA.

Email: [email protected]

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L. Grisell Diaz-Ramirez MS

L. Grisell Diaz-Ramirez MS

Health Service Research and Development, San Francisco Veterans Affairs Healthcare System, San Francisco, California, USA

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W. John Boscardin PhD

W. John Boscardin PhD

Division of Geriatrics, Department of Medicine, UCSF, San Francisco, California, USA

Health Service Research and Development, San Francisco Veterans Affairs Healthcare System, San Francisco, California, USA

Division of Biostatistics, Department of Epidemiology and Biostatistics, UCSF, San Francisco, California, USA

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Alexander K. Smith MD

Alexander K. Smith MD

Division of Geriatrics, Department of Medicine, UCSF, San Francisco, California, USA

Health Service Research and Development, San Francisco Veterans Affairs Healthcare System, San Francisco, California, USA

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Sei J. Lee MD, MAS

Sei J. Lee MD, MAS

Division of Geriatrics, Department of Medicine, UCSF, San Francisco, California, USA

Health Service Research and Development, San Francisco Veterans Affairs Healthcare System, San Francisco, California, USA

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First published: 06 July 2022
Citations: 4

Alexander K. Smith and Sei J. Lee contributed equally to this work as senior authors.

Funding information: National Institute on Aging, Grant/Award Numbers: K24AG066998, K24AG068312, R01AG047897, T32AG212000, U01AG009740

Abstract

Background

Many clinical and financial decisions for older adults depend on the future risk of disability and mortality. Prognostic tools for long-term disability risk in a general population are lacking. We aimed to create a comprehensive prognostic tool that predicts the risk of mortality, of activities of daily living (ADL) disability, and walking disability simultaneously using the same set of variables.

Methods

We conducted a longitudinal analysis of the nationally-representative Health and Retirement Study (HRS). We included community-dwelling adults aged ≥70 years who completed a core interview in the 2000 wave of HRS, with follow-up through 2018. We evaluated 40 predictors encompassing demographics, diseases, physical functioning, and instrumental ADLs. We applied novel methods to optimize three models simultaneously while prioritizing variables that take less time to ascertain during backward stepwise elimination. The death prediction model used Cox regression and both the models for walking disability and for ADL disability used Fine and Gray competing-risk regression. We examined calibration plots and generated optimism-corrected statistics of discrimination using bootstrapping. To simulate unavailable patient data, we also evaluated models excluding one or two variables from the final model.

Results

In 6646 HRS participants, 2662 developed walking disability, 3570 developed ADL disability, and 5689 died during a median follow-up of 9.5 years. The final prognostic tool had 16 variables. The optimism-corrected integrated area under the curve (iAUC) was 0.799 for mortality, 0.685 for walking disability, and 0.703 for ADL disability. At each percentile of predicted mortality risk, there was a substantial spread in the predicted risks of walking disability and ADL disability. Discrimination and calibration remained good even when missing one or two predictors from the model. This model is now available on ePrognosis (https://eprognosis.ucsf.edu/alexlee.php)

Conclusions

Given the variability in disability risk for people with similar mortality risks, using individualized risks of disabilities may inform clinical and financial decisions for older adults.

CONFLICT OF INTEREST

All authors declare no conflicts of interest.