Disability is no dead-end for elders, Yale research finds

Between the daunting complexities of Medicare’s new prescription drug plans, the uncertainties surrounding the solvency of Social Security and the rising rates of Alzheimer’s disease and other ailments of the elderly, it would seem that bad news about America’s older persons decidedly outweighs the good. But over the past nine years, geriatrics researcher and Associate Professor of Medicine Thomas M. Gill, M.D., has pieced together some surprising and uplifting news about disability among our aging population using a simple but powerful tool: the telephone.

In 1997, Gill enrolled over 750 elderly New Haven-area residents in an ambitious study known as the Precipitating Events Project (PEP). Since then, over the course of 55,000 telephone interviews and 3,200 at-home visits with the study participants, Gill and his team have overturned previous views about chronic disability among the elderly and revealed that older Americans surmount most physical setbacks with remarkable resiliency.

In November, the National Institute on Aging recognized Gill’s accomplishments with a $3.2 million MERIT award—a designation reserved for the “most outstanding” grant proposals “from superior researchers”—that will allow him to continue to follow his original study group for several more years.

When Gill arrived at Yale as a Robert Wood Johnson Clinical Scholar in 1993, national survey data indicated that the rate of chronic disability—defined as disability lasting at least three months—among older persons had fallen markedly over the previous 20 years, probably due to a decline in smoking and advances in cardiovascular and orthopaedic medicine such as coronary bypass surgery, anti-hypertensive drugs and prosthetic knee and hip replacements. But the same surveys showed that this trend had been offset by the overall aging of the population, so the conventional wisdom in geriatrics held that, despite improvements in medical care, the total number of chronically disabled older Americans had remained about the same.

However, the surveys in question were conducted two to five years apart and required many participants to rely on their memories of past disabling events—and sometimes even asked respondents to predict future disability. Gill launched PEP to explore whether a finer-grained and less subjective analysis might yield a more reliable picture of chronic disability. Over the course of the study, the PEP research team has conducted phone interviews with each study participant every month and has paid them personal visits every 18 months. And participants’ commitment to the project has been extraordinary, according to Gill.

“PEP was originally envisioned as lasting only two or three years, but it’s exceeded our wildest expectations,” Gill says. “Our completion rate for these telephone interviews is 99 percent. We have very little missing data, and very few participants—about 4 percent—have dropped out over the course of the study. We follow individuals in and out of hospitals, in and out of nursing homes, and when they make a transition between living in the community to assisted living.”

This sustained and regular contact between PEP researchers and participants has yielded a new, more nuanced view of the challenges presented by disability in old age. “When you look every month, the rates of disability over time are much higher than those shown in the single snapshots of surveys,” Gill says. “The difference was dramatic, and the only way that could happen is if people were recovering at much higher rates than had previously been reported. Prior reports said that about a third of older people will recover after a disabling event, but we found that when you look carefully, every month, these recovery rates are up to 80 percent.”

The bottom line, Gill says, is that for most older persons disability is not irreversible, but a recurrent event from which they recover. Therefore, there are probably about 5 million chronically disabled older Americans at any given time, 2 million fewer than estimated by previous research. This means that the total impact of disability on the health care system may be much smaller than predicted by older studies.

Gill says that the medical school’s long-standing tradition in geriatrics research, exemplified by the Yale Program on Aging and the Claude D. Pepper Older Americans Independence Center, have played no small part in PEP’s success. “A project like this would be difficult to pull off without the Pepper Center and the Program on Aging because they provide a stable cadre of superb researchers who’ve been moving from project to project over the past 20 years with established links to the community,” Gill says. “That cannot be replicated.”