Cardiovascular disease and functional ability in older adults
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Preservation of functional independence is important to older adults. The consequences of functional impairment (increased dependence on others for activities of daily living and requirement for nursing home care) place a significant burden on older people, their families and health care systems. Prevention of functional impairment is of considerable importance, and requires the systematic identification of modifiable determinants of loss of independence in activities of daily living to develop interventions to prevent this loss. My thesis addresses the association of cardiovascular disease and cardiovascular risk factors with functional impairment in older adults, identifies the importance of functional outcome measures in cardiovascular research and proposes an approach to evaluating the effect of vascular risk factor modification on loss of function. Employing a number of different methodological and statistical approaches (with a particular focus on hypertension), I report the association between vascular risk factors and functional impairment in community dwelling older adults in cohort studies and systematic review of clinical trials, I explore attitudes of individuals to the importance of measuring functional outcomes in trials of cardiovascular prevention, and evaluate different methodological approaches to estimating the effect of interventions with effects on multiple outcomes. Finally, I describe a protocol for a randomised controlled trial to determine whether lowering blood pressure in older adults with mild hypertension (without cardiovascular disease) reduces the risk of functional impairment. Findings from my thesis emphasise the importance of modifiable vascular risk factors in the development (and prevention) of loss of independence for activities of daily living, mediated largely through clinical and covert cardiovascular disease. Despite this association, and the importance of functional outcome measures to the general public, cardiovascular prevention trials rarely report functional outcome measures. My thesis proposes a paradigm change in selecting outcome measures for cardiovascular prevention trials in older adults, to include functional outcomes.