Socio-health factors, ability to perform instrumental and basic activities of daily living, and use of assistive mobility devices during the COVID-19 pandemic: Interrelationships and impact on long-term survival

Abstract

Introduction: Functional dependence for the performance of basic activities of daily living (ADLs) is one of the main causes of institutionalization. This study analyzed the interrelationships between basic and instrumental activities of daily living, use of assistive mobility devices, socioeconomic factors, changes during COVID-19 pandemic confinement, and 3-year survival in the ADL-dependent people of the Orcasitas neighborhood of Madrid (Spain).

Methods: A longitudinal descriptive study, carried out on the entire population of functional dependent patients (Barthel ≤ 60) in the Orcasitas neighborhood. We included 127 patients, 78.7% women and 21.3% men, with a mean age of 86 years. Pre-pandemic, post-confinement (June 2020) and June 2023 data were contrasted.

Results: Results: The use of crutches-cane was associated with a higher probability of being independent in performing ADLs, leaving home (OR 4.848; CI 1.428-16.458), improving functional capacity during confinement (OR 3.621; CI 1.409-9.308), and even ceasing to be functionally dependent (OR 0.394; CI 0.165-0.941). Using a wheelchair was associated with a higher level of dependency (OR 2.583; CI 1.167-5.714) and higher mortality (HR 1.913; CI 1.106-3.309). After COVID-19 pandemic confinement, having a financial income of less than 11,200 euros/year (OR 2.413; CI 1.159-5.023), or using a wheelchair (OR 2.464; CI 1.009-6.017), increased the risk of living homebound. Living homebound decreased the probability of survival, while maintaining the ability to leave home increased it (OR 3.880; CI 1.834-8.211). Economic capacity modulated the results. Lower economic capacity was associated with higher mortality (HR 2.47 (Exp(B) 0.405; CI 0.232-0.708). Living in confinement and having a low economic income were associated with higher mortality (OR 0.127; CI 0.029-0.562), mortality that was also higher with respect to those who could leave their home (OR 6.697; CI 2.084-21.525).

Conclusions: Functional ADL-dependence affects multiple facets of the person. Confinement triggered changes in the baseline conditions of this cohort, which were influenced by the level of dependency, mobility capacity and economic income level. Economic capacity modulated the results, showing that social inequalities influence survival. The ability to leave home and the use of a wheelchair should be included in the assessment of the risk level of this population group.

Fig 1. Autonomy, COVID-19 pandemic confinement and survival.

Interrelationships. Representative diagram of the analysis of the interrelationships between the variables associated with functional dependence and the variables directly or indirectly associated with mobility. The influence of confinement to the usual home due to the COVID-19 pandemic was also analyzed for each node.

Fig 2. Influence of COVID-19 confinement on the ability to leave home and survival.

Survival at three years of follow-up in relation to the changes produced during COVID-19 confinement in the mode of living in the community of persons with functional dependence in the Orcasitas cohort.

Fig 3. Network analysis for mobility. Network analysis of mobility, reflected by the interrelationships between the mode of living in the community, estimated by the ability to leave home or the situation of homebound living, and the use of assistive mobility devices according to the mode of living.

Influence of mobility, level of dependency and economic level on survival at three years of follow-up. The values behind this network analysis (points, edges) are given in S1 Text.

Fig 4. Level of functional dependence and availability of assistants.

Availability of assistants for housework or live-in caregivers depending on the level of dependency. Coexistence of different types of assistants in relation to the level of dependency.

Fig 5. Level of functional ADL-dependency and weekly hours of public assistance for housework.

Assistants assigned for housework by social services. Number of hours per week for each level of dependence on the Barthel index.

Fig 6. Survival-mortality network analysis for chronic diseases.

Survival-mortality network analysis in relation to the chronic diseases present in the population with functional dependence of the Orcasitas cohort, according to living homebound or having the ability to leave home. Influence of the level of functional dependence and economic level on survival in both groups.

Fig 7. Cox regression: mortality risk associated with income level in wheelchair users.

Association between level of economic income and survival at three years of follow-up in persons with functional ADL-dependence who were wheelchair users.

Fig 8. Panel A: Cox regression: mortality risk associated with mode of living in the community.

Survival at three years follow-up in relation to maintaining before COVID-19 pandemic confinement the ability to leave home. Panel B: Cox regression: mortality risk associated with mode of living in the community. Survival at three years follow-up in relation to maintaining after COVID-19 pandemic confinement the ability to leave home.

Fig 9. Influence of economic capacity on the mode of living in the community.

Interrelationships between level of economic income and level of dependency with living in the community being able to leave home before and after confinement or living homebound.

Fig 10. Panel A: Network analysis before COVID-19 confinement.

Network analysis of the interrelationships between level of dependence, economic level, and mode of living in the community of people with functional dependence in the Orcasitas cohort. Analysis of the baseline situation before confinement due to the COVID-19 pandemic and influence on survival at three years. Panel B: Network analysis after COVID-19 confinement. Network analysis of the interrelationships between level of dependency, economic status, and mode of living in the community after COVID-19 pandemic confinement and their influence on survival at three years. Analysis of changes associated with COVID-19 pandemic confinement.