INT’L. J. AGING AND HUMAN DEVELOPMENT, Vol. 77(4) 309-329, 2013

RESTRICTION IN INSTRUMENTAL ACTIVITIES OF DAILY LIVING IN OLDER PERSONS: ASSOCIATION WITH PREFERENCES FOR ROUTINES AND PSYCHOLOGICAL VULNERABILITY* VALÉRIE BERGUA JEAN BOUISSON University Bordeaux, France JEAN-FRANÇOIS DARTIGUES University Bordeaux, France and INSERM, ISPED, Bordeaux, France JOEL SWENDSEN University Bordeaux, France; CNRS, INCIA, Bordeaux, France; and EPHE Sorbonne, Paris, France COLETTE FABRIGOULE University Bordeaux, France and CNRS, INCIA, Bordeaux, France KARINE PÉRÈS PASCALE BARBERGER-GATEAU University Bordeaux, France and INSERM, ISPED, Bordeaux, France

*This research was based on the PAQUID project funded by: ARMA (Bordeaux) - Caisse Nationale d’Assurance Maladie des Travailleurs Salariés (CNAMTS) - Conseil Général de la Dordogne - Conseil Général de la Gironde - Conseil Régional d’Aquitaine – Fondation de France – France Alzheimer (Paris) - Institut National de la Santé et de la Recherche Médicale (INSERM) – GIS Longévité - Mutuelle Générale de l’Education Nationale (MGEN) - Mutualité Sociale Agricole (MSA) – NOVARTIS Pharma (France) – SCOR Insurance (France) – AGRICA (France). 309 Ó 2013, Baywood Publishing Co., Inc. doi: http://dx.doi.org/10.2190/AG.77.4.c http://baywood.com

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Disabilities in the Instrumental Activities of Daily Living (IADL) are frequently observed in older adults. A restriction in the daily life activities in the elderly may be related to a process of routinization induced by homogenization of activities, in addition to its association with emotional states. The relationship between level of functional disability for IADLs and preferences for routines was explored in 207 non-demented French participants (Mage = 84.2 years, age range: 78-96 years) from the PAQUID cohort study. Multinomial regressions analyses showed that preferences for routines were significantly associated with a higher risk of restriction for at least two functional activities, after adjusting for sociodemographic and psychological variables. However, this association was non significant after controlling for cognitive variables. These findings add new elements for understanding the effect of routinization in the disability process in older persons in that preferences for routines could constitute a risk factor of IADL restriction, similar to cognitive decline.

Progressive activity restriction is a common feature of most elderly persons (Mor et al., 1989; Stuck et al., 1999; Femia, Zarit, & Johansson, 2001). As defined by the International Classification of Functioning, Disability and Health (WHO, 2001), the concept of “activities” refers to the execution of a range of tasks at an individual level. Consistent with Lawton’s hierarchical model (Lawton & Brody, 1969), Instrumental Activities of Daily Living (IADL) require the individual to cope with environmental demands through adaptive tasks. Activity restriction is observed in different IADLs before being detected in more basic activities such as physical self-maintenance (Asberg & Sonn, 1988; BarbergerGateau, Rainville, Letenneur, & Dartigues, 2000; Spector, 1990). This difference is explained by the fact that IADLs require a higher level of functioning not only in domestic tasks characterized by low cognitive involvement (e.g., housekeeping, food preparation), but also in more elaborate activities such as using the telephone or handling finances that require the integrity of intellectual functions for optimal performance (Barberger-Gateau, Fabrigoule, Rouch, Letenneur, & Dartigues, 1999a). This association between IADL and neuropsychological performance is found in “normal” aging (Barberger-Gateau et al., 1999a). In particular, slight restrictions in four IADLs (telephone communication, transportation use, taking medication, and handling finances) have a strong association with cognitive performance (Barberger-Gateau, Fabrigoule, Helmer, Rouch, & Dartigues, 1999b). The successful completion of these activities also involves the integration of body structures and functions in a purposeful manner within various contexts (Arthanat, Nochajski, & Stone, 2004). It is therefore not surprising that diverse predictors of restriction in daily activities have been observed (Stuck et al., 1999). Most notably, these predictors include sociodemographic variables

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associated both with cognitive decline (Aguerro-Torres, Thomas, Winblad, & Fratiglioni, 2002; Barberger-Gateau et al., 1992, 1999b; Peres et al., 2005; Pfeffer, Kurosaki, Harrah, Chance, & Filos, 1982), and somatic pathologies (e.g., cardiovascular disease, cancer) which have an independent and debilitating effect on daily behaviors and IADLs (Aguerro-Torres et al., 2002, Peres et al., 2005). Additional studies have also investigated the contribution of psychological vulnerability in functional disability, in particular concerning psychological attributes such as perceived control and neuroticism (Jang, Haley, Mortimer, & Small, 2003; Kempen et al., 1999), and emotional states such as depressive symptomatology, anxiety or inactivity (Barberger-Gateau et al., 1992; Kiosses & Alexopoulos, 2005; Lauderdale & Sheikh, 2003; Nourhashemi et al., 2001; Ormel, Rijsdijk, Sullivan, Van Sonderen, & Kempen, 2002; Yang & George, 2005). According to the model of Verbrugge and Jette (1994), the disablement process denotes a relationship between a person and her/his environment. Intra-individual factors have been defined as individual reactions to functional disability, such as lifestyle, behavioral changes, psychosocial characteristics, coping strategies, or activity accommodations. They are associated with the acceleration or the slowing down of the disablement process. More specifically, the preferences of the individual in the manner in which daily life is structured, or “preferences for routines” (PRS) as defined by Bouisson and Swendsen (2002), may be related to restriction in activities of daily living. Although the increasing of routinization in older people are commonly understood as a natural or adaptive process (Bouisson, 2002; Kastenbaum, 1984; Reich & Zautra, 1991), recent investigations have underscored their role as a marker of vulnerability in emotional (anxiety and depression), cognitive (Bergua et al., 2006; Bouisson & Swendsen, 2003; Tournier, Mathey, & Postal, 2012), and functional domains (Bergua et al. 2006; Zisberg, Zisberg, Young, & Schepp, 2009). Increased PRS may indicate a loss of resources which could prevent older persons from achieving an efficient adaptation to loss, therefore rendering them more vulnerable in everyday functioning (Bergua et al., 2006; Bergua, Dartigues, & Bouisson, 2012). PRS have also been shown to be directly associated with IADL disability in different samples, including older persons suffering of dementia (Bergua et al., 2006) and among the healthy elderly (Zisberg et al., 2009, using a scale of trait routinization). It seems, however, that this association is best understood before the onset of dementia, and examined through common risk factors such as depressive, anxiety symptoms, and cognitive decline (Bergua et al., 2006). In this way, PRS may reflect the individual’s response to perceived or objective decline. As it is associated with psychological vulnerability, it may induce a restriction in behaviors in the pursuit of fewer, less complex, and more predictable activities. The purpose of the present investigation was to define in non-demented older persons the level of IADL restriction that is associated with activity routinization, while taking into account established sociodemographic and clinical risk

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factors (in emotional and cognitive domains) of functional decline and preferences for routines. This investigation is based on a part of a large-scale epidemiological study, “PAQUID” (“Personnes Âgées QUID”), and included nondemented older persons living in private residences in southern France. It is hypothesized that PRS, taken as a general marker of vulnerability, would be associated with restriction on several or all the IADLs, independently of other clinical and sociodemographic risk factors implicated in the restriction of daily activities.

METHOD This study is based on the 13th-year follow-ups of the PAQUID cohort study. The general methodology of the PAQUID study and the characteristics of the sample have been described in detail elsewhere (Barberger-Gateau et al., 1992; Dartigues et al., 1991, 1992). In brief, this prospective cohort study began in 1988 with a sample of 3,777 older adults, aged 65 or older and living independently in two departments (Dordogne and Gironde) of southern France. The initial sample was representative in terms of age and gender of the general population of this age range (Dartigues et al., 1992). Participants The present study is based on a sub-sample of the PAQUID cohort who were administered new instruments measuring preferences for routines and trait anxiety added to the 13-year follow-up and only for the Dordogne site of the study (not in Gironde). As presented in Figure 1, among the 392 individuals living at home and seen at T13 in Dordogne, 157 were excluded from the present sample because they did not complete the PRS (Bouisson, 2002). In a large proportion of cases, missing data were due to cognitive problems or to participant refusal due to fatigue or depressed mood. Among the 157 individuals concerned by missing data on the PRS, 54 were classified as having dementia. The descriptive analyses indicated that individuals who declined to respond were older (F(1, 392) = 17.6, p < .001), more likely to be female (c2(2, 392) = 14.8, p < .001), and more likely to have a low educational level (c2(2, 392) = 8.9, p < .01). On the 235 persons who completed this measure, 28 additional persons with dementia were excluded because of the potential lack of reliability of their answers on the preferences for routines scale, reducing the sample from 235 to 207 eligible individuals. A flow chart reporting sample selection is presented in Figure 1. In addition, all participants did not complete all neuropsychological tests which explain some variations in sample size.

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Figure 1. Study flow chart.

Materials and Procedure Psychologists trained specifically for the study conducted an hour-long interview in the homes of participants at baseline, and at follow-ups were carried out at 3, 5, 8, 10, and 13 years after inclusion. The data collected included basic sociodemographic information and measures of physical and mental health. At the end of each interview, the Mini Mental State Examination (MMSE) and a set of neuropsychological tests were administered, followed by an assessment of dementia using DSM-III criteria (American Psychiatric Association [APA], 1987). A neurologist then reviewed the positive cases of dementia to confirm or invalidate the diagnosis and to ascertain its etiology. Materials Functional Assessment

Restrictions in activities of daily living were assessed by the French translation of the Lawton’s IADL scale (Lawton & Brody, 1969). The four items specifically associated with cognitive performance were used in the present study and include telephone communication, transportation use, taking medication, and handling finances (Barberger-Gateau et al., 1999b). An individual was considered as restricted for an activity if he or she could not perform this activity at the highest level of performance. For example, full independence concerning telephone use requires being able to operate telephone on own

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initiative whereas the first level of restriction corresponds to only being able to dial a few well-known numbers. Restriction for each activity was represented by a single item coded 0 (fully independent) versus 1 (at least slightly restricted). The number of IADLs for which a given individual was considered to be “restricted” was then summed, leading to a score ranging from 0 to 4. This 4-IADL score has satisfactory internal consistency (a = 0.76) (Barberger-Gateau et al., 1992). Preferences for Routines

At the 13-year follow-up only, preferences for routines were assessed by the Preferences for Routinization Scale (PRS) (Bouisson, 2002). This 10-item French-language measure used 5-point Likert scales and the total score ranged from 10 to 50. The PRS assess the degree to which the participant generally agrees with statements about doing tasks in a particular order or about the desirability of changes to daily life routines. These items primarily assessed daily behaviors in the older people, such as daily rhythms and activities, and intentionally excluded questions likely to assess personality dimensions (such as obsessionality). Examples of items include “Generally, I do the same things each day,” or “I like to move and change activities” (see Appendix for the details of the scale). The French version of PRS has been shown to have acceptable internal consistency (a = 0.73), high test-retest reliability over a 2-week period (r = 0.84), and to be appropriately brief for use with very old or disabled participants (Bouisson, 2002). In the present study, we found a lower alpha coefficient of 0.50. However, strong support has been found for the predictive validity of the PRS as a measure of actual behavioral routinization in daily life in that preferences predicted the repetition of both specific behaviors and environmental contexts during the same time periods across different days (Bouisson & Swendsen, 2003). Sociodemographic Covariates

The sociodemographic data included age, gender, marital status (married, widowed, other) and educational level, dichotomized into two groups: participants without schooling or having only a primary level (the French “Certificat d’Etudes Primaires”: CEP, equivalent to 7 years of schooling), and those with greater than 7 years of education. We have also considered the number of current medications taken as a marker of co-morbidity. These medications were collected by psychologists during the interview at home. Psychological Covariates

Depressive symptomatology: The presence of depressive symptoms was assessed by the Center for Epidemiological Studies Depression Scale (CESD)

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(Radloff, 1977). This 20-item self-report questionnaire asks participants to indicate their experience over the previous week of different depressive symptoms on a 4-point scale over the previous week. The CESD has been found to be internally consistent (alphas ranging from .84 to .90) and the French translation demonstrated similar properties (Fuhrer & Rouillon, 1989). In the present study, we observed an alpha coefficient of 0.83. The validity and utility of the CESD for evaluation of depressive symptomatology in older populations have also been established (Dufouil, Dartigues, & Fuhrer, 1995; Hertzog, Van Alstine, Usala, Hultsch, & Dixon, 1990). Trait anxiety: Trait anxiety was assessed using the State-Trait Anxiety Inventory Form Y (Spielberger, Gorsuch, & Lushene, 1983). Respondents are asked to indicate how they “generally feel” on a 4-point scale with respect to 20 different anxiety-related items. The scale has been found to be reliable and internally consistent (alphas ranging from .86 to .95) (Spielberger et al., 1983). The French version (Bruchon-Schweitzer & Paulhan, 1993) has maintained the psychometric properties of the original version, and similar psychometric properties in older adults have been demonstrated (Stanley & Beck, 2000). In the present study, we observed an alpha coefficient of 0.87. Cognitive Covariates

A set of neuropsychological tests was administered at the 13-year follow-up: 1. The French version of the MMSE (Folstein, Folstein, & McHugh, 1975) was administered as a general assessment of cognitive functioning and global mental status; 2. The Benton Visual Retention Test (BVRT) (Benton, 1965) with the multiplechoice form (Form F) was used to explore immediate visual memory but also selective attention. Possible scores range from 0 to 15, increasing with the number of correct answers; 3. The Wechsler Paired Associates Test (WPAT) (Wechsler, 1945) is a verbal associative memory test. We used the first recall measure in the present study; 4. The Digit Symbol Substitution Test (DSST) (Wechsler, 1981) is a measure of processing speed and executive capacity. The score sums up the number of symbols properly copied in a time period of 90 seconds; 5. The Isaacs Set Test (IST) (Isaacs & Akhtar, 1972) is a categorical verbal fluency test that measures the ability to generate lists of words in four semantic categories (colors, animals, fruit, cities) in a time period limited to 60 seconds; 6. An abbreviated version of Zazzo’s Cancellation Task (ZCT) (Zazzo, 1964) which assesses visuo-spatial perception and selective attention, with a

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measure of cognitive speed using a form with eight lines composed of 25 symbols. We considered the number of symbols correctly identified and the time spent to analyze the eight lines of the form as a measure of response speed; and 7. The first five items of the WAIS Similarities Test (WST) was used to explore conceptual abilities (Wechsler’s Adult Intelligence Scale, 1981). Only the first five pairs of the test were considered and the score ranged from 0 to 10. Statistical Methods ANOVA and chi-square comparisons were first used to assess the significance of the association of the IADL scores with the individual sociodemographic and clinical factors. Univariate linear regressions were also used to assess the association between these factors and preferences for routines. The most pertinent variables identified through these preliminary analyses (using a threshold of 0.15 as recommended by Hosmer and Lemeshow, 2000) and considered as potential confounders were then included in multinomial logistic regression models to examine the specific association between routinization scores and different activity restriction levels. These confounders were grouped into three blocks including sociodemographic, emotional, and cognitive variables, respectively. Each block was applied successively into multinomial regressions models to determine the contribution of the routinization after these variables have been introduced. The first model included sociodemographic variables, the second model included both sociodemographic and psychological variables, the third model included both sociodemographic and cognitive variables, and the fourth included all previous variables. We used a backward stepwise procedure with all covariates into each block in order to retain only the most significant covariates among sociodemographic, psychological, and cognitive domains. IADL scores were considered here as an ordinal outcome variable with a score ranging from 0 to 4, increasing with the level of severity of IADL restriction. The log odds of this IADL scores is modeled as a linear combination of the predictor demographic and clinical variables. Statistical analyses were carried out using IBM® SPSS® 18.0 for Windows (SPSS, 2009).

RESULTS Concerning the final sample of 207 participants, 75% had more than 7 years of education and 58% were widowed (in majority women, 70.5%, p < .001). The mean scores on MMSE and PRS were 26.5 (SD = 2.3) and 30.6 (SD = 6.7),

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respectively. Finally, 53% of the sample was considered as restricted on at least one of the 4 IADLs measures. Using the 4-IADL score as a continuous variable, there was a significant correlation with the PRS score (Pearson correlation; r = 0.13; p < .05). However, given the small number of subjects considered as restricted for 3 IADLs (13 subjects or 6.3% of the sample) or 4 IADLs (6 subjects or 2.9% of the sample) only three categories were used in further analyses: restriction for none of the 4 IADLs, restriction for 1 IADL, and restriction for 2 or more IADLs. The results of ANOVA and chi-square analyses (see Table 1) demonstrate that increasing IADL restriction was associated with sociodemographic variables including advanced age, female gender, lower educational level, and widowhood. The number of medications was also positively associated with the degree of IADL restriction. Moreover, higher IADL restriction levels were associated with higher depression and anxiety but also with cognitive functioning (on all measures except the WPAT). Concerning the preferences for routines, the results of univariate linear regressions in Table 2 did not show significant associations with sociodemographic variables and cognitive functioning. However, preferences for routines were significantly associated with psychological variables (anxiety and depression). Multinomial logistic regressions analyses were then conducted by entering the most pertinent correlates of IADL restriction and preferences for routines identified through these univariate analyses using a threshold of 0.15. These variables included gender, age, educational level, and medications among sociodemographic variables, psychological variables (CESD and STAI scores), and cognitive variables the most associated with routinization including BVRT score, IST score, and ZCT score. Given the strong correlation between CESD and STAI scores (r = 0.69; p < .001), and also between cognitive measures (see Table 3), we used a backward stepwise procedure with these covariates into each block. Results of the final models are given in Table 4. The first model showed that after controlling for sociodemographic variables and medication, restriction for 2 or more IADLs, compared to no restriction in daily activities, was significantly associated with preferences for routines. By contrast, restriction for 1 of the 4 IADLs was not significantly associated with greater preferences for routines. The second model included both sociodemographic and psychological variables, and showed similar results after backward stepwise procedure into the psychological block. Preferences for routines remain significantly associated with restriction for 2 or more IADLs, even when taking into account depressive symptomatology. However, in the third model, the adjustment for cognitive variables removed the effect of preferences for routines on restriction for IADL. In the same way, the fourth model showed that restriction for IADL was not explained by preferences for routines after controlling for sociodemographic, psychological, and cognitive variables.

7.1 (5.8) 33.2 (8.4)

Psychological variables CESD score, mean (SD) STAI score, mean (SD) 26.5 (1.8) 10.3 (1.8) 5.3 (1.9) 25.4 (8.1) 26.5 (6.6) 101.4 (27.7) 8.2 (2.0)

10.8 (8.1) 37.9 (9.1)

30.4 (5.7)

69.4 84.5 (3.6) 77.5 57.1 5.7 (2.9)

1 N = 61

25.4 (2.1) 10.1 (2.1) 4.7 (1.8) 18.9 (6.3) 23.2 (4.6) 115.7 (40.3) 7.4 (2.1)

12.5 (9.2) 37.5 (11.2)

32.2 (6.4)

68.2 84.7 (3.8) 45.4 68.2 6.8 (3.5)

2, 3, or 4 N = 49

0.00* 0.00* 0.09 0.00* 0.00* 0.00* 0.02*

0.00* 0.01*

0.12

0.00* 0.00* 0.00* 0.00* 0.03*

Comparison within IADL score (ANOVA/c2)

0.37 0.32 0.17 0.31 0.27 0.34 0.22

0.31 0.29

0.14

0.35 0.32 0.25 0.27 0.19

Effect size (h2/jc)

*Significativity; SD = Standard Deviation. Notes: IADL (Instrumental Activities of Daily Living; Lawton & Brody, 1969); 4-IADL score (Barberger-Gateau et al., 1992); PRS (Preferences for Routines Scale; Bouisson, 2002); CESD (Center for Epidemiologic Studies of Depression scale; Radloff, 1977); STAI (State-Trait Anxiety Inventory; Spielberger et al., 1983); MMSE (Mini Mental State Examination; Folstein et al., 1975); BVRT (Benton Retention Visual Test; Benton, 1965); WPAT (Wechsler Paired Associates Test; Wechsler, 1945); DSST (Digit Symbol Substitution Test; Wechsler, 1981); IST (Isaacs Set Test; Isaacs & Akhtar, 1972); ZCT (Zazzo’s Cancellation Task; Zazzo, 1964); WST (Wechsler Similarities Test; Wechsler, 1981).

27.5 (1.9) 11.5 (1.9) 5.7 (2.1) 26.9 (8.8) 27.9 (5.6) 87.0 (26.0) 8.7 (1.9)

29.8 (7.2)

Routinization PRS score, mean (SD)

Cognitive variables MMSE score, mean (SD) BVRT score, mean (SD) WPAT score, mean (SD) DSST score, mean (SD) IST score, mean (SD) ZCT score, mean (SD) WST score, mean (SD)

34.4 82.9 (3.0) 84.4 36.6 5.3 (3.1)

Sociodemographic variables Female gender, % Age, mean (SD) Educational level (1st grade), % Widowhood, % Number of medications, mean (SD)

0 N = 97

IADL score

Table 1. Associations between Sociodemographic, Psychological, and Cognitive Variables and Each Value of the 4-IADL Score (N = 207)

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8.9 (7.8) 33.9 (8.8) 26.5 (2.6) 11.3 (1.7) 5.4 (2.2) 25.2 (8.3) 60.5 (13.7) 27.1 (2.1) 96.9 (34.9) 8.2 (2.1)

Psychological variables CESD score, mean (SD) STAI score, mean (SD)

Cognitive variables MMSE score, mean (SD) N = 207 BVRT score, mean (SD) N = 187 WPAT score, mean (SD) N = 183 DSST score, mean (SD) N = 181 IST score, mean (SD) N = 198 ZCT score, mean (SD) N = 186 ZCT time, mean (SD), N = 185 WST score, mean (SD) N = 206 26.8 (2.2) 10.8 (2.2) 5.7 (2.0) 25.2 (9.3) 58.1 (15.7) 27.4 (1.5) 94.9 (27.8) 8.3 (2.2)

7.7 (5.3) 34.8 (8.4)

47.4 84.0 (3.2) 78.9 42.1 5.9 (3.1)

Quartile 2 26 £ PRS £ 30 N = 57

26.2 (2.0) 10.3 (1.8) 5.0 (1.8) 22.6 (7.3) 53.5 (15.3) 27.3 (2.5) 101.1 (34.1) 7.9 (2.3)

10.5 (8.5) 37.9 (11.0)

56.9 84.8 (4.1) 74.5 58.8 5.9 (3.4)

26.5 (2.3) 10.7 (2.5) 5.1 (2.3) 25.6 (10.2) 55.6 (13.1) 27.8 (1.5) 94.9 (30.7) 8.0 (2.1)

12.2 (9.5) 38.6 (10.7)

51.0 83.5 (3.6) 76.5 49.0 6.2 (2.6)

Quartile 4 Quartile 3 31 £ PRS £ 34 35 £ PRS £ 50 N = 51 N = 51

–0.05 –0.11 –0.08 –0.01 –0.12 0.14 0.01 –0.07

0.17 0.18

–0.03 –0.01 0.02 0.06 0.12

b

0.20 0.23 0.24 0.06 0.03 0.25 0.01 0.22

0.06 0.05

0.93 0.12 1.08 0.93 0.14

SE

0.003 0.013 0.007 0.000 0.015 0.019 0.000 0.004

0.028 0.032

0.001 0.000 0.001 0.003 0.015

R2

0.45 0.12 0.28 0.91 0.09 0.06 0.88 0.36

0.02* 0.01*

0.61 0.89 0.74 0.42 0.08

p

Univariate linear regressions

*Significativity; SD = Standard Deviation; b = Standardized coefficient; SE = Standard Errors. Notes: PRS (Preferences for Routines Scale; Bouisson, 2002); CESD (Center for Epidemiologic Studies of Depression scale; Radloff, 1977); STAI (State-Trait Anxiety Inventory; Spielberger et al., 1983); MMSE (Mini Mental State Examination; Folstein et al., 1975); BVRT (Benton Retention Visual Test; Benton, 1965); WPAT (Wechsler Paired Associates Test; Wechsler, 1945); DSST (Digit Symbol Substitution Test; Wechsler, 1981); IST (Isaacs Set Test; Isaacs & Akhtar, 1972); ZCT (Zazzo’s Cancellation Task; Zazzo, 1964); WST (Wechsler Similarities Test; Wechsler, 1981).

56.2 84.5 (4.1) 72.9 45.8 5.1 (3.6)

Sociodemographic variables Female gender, % Age, mean (SD) Educational level (1st grade), % Widowhood, % Number of medications, mean (SD)

Quartile 1 10 £ PRS £ 25 N = 48

PRS score

Table 2. Association between Sociodemographic, Psychological, Cognitive Variables, and the PRS Score in Quartiles and in Continuous Score (N = 207)

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Table 3. Intercorrelations between Cognitive Variables Variables

1

2

3

4

5

1. MMSE score, N = 207



.42**

.40**

.50**

.48**

.20** –.20** .50**



.26**

.39**

.45**

.11

–.28** .32**



.33**

.35**

.08

–.16** .36**



.62**

.11

–.37** .45**



.11

–.36** .42**

2. BVRT score, N = 187 3. WPAT score, N = 183 4. DSST score, N = 181 5. IST score, N = 198 6. ZCT score, N = 186

6



7. ZCT time, N = 185

7

–.05



8. WST score, N = 206

8

.10

–.11



Note: Pearson correlations; **p < 0.01; *p < 0.05; MMSE (Mini Mental State Examination; Folstein et al., 1975); BVRT (Benton Retention Visual Test; Benton, 1965); WPAT (Wechsler Paired Associates Test; Wechsler, 1945); DSST (Digit Symbol Substitution Test; Wechsler, 1981); IST (Isaacs Set Test; Isaacs & Akhtar, 1972); ZCT (Zazzo’s Cancellation Task; Zazzo, 1964); WST (Wechsler Similarities Test; Wechsler, 1981).

DISCUSSION Based on a subsample from a large cohort of older people living independently, the objective of the present investigation was to explore the association of different levels of IADL restriction with preferences for routines while adjusting for diverse sociodemographic and clinical risk factors. The present results are consistent with the previous studies (Bergua et al., 2006; Zisberg et al., 2009) indicating a relation between functional status and routinization. Moreover, as hypothesized, the findings demonstrate a more specific association of greater preferences for routines with functional restrictions for at least 2 IADLs, independently of sociodemographic characteristics, medications, and depressive

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symptomatology. In other words, older adults with at least 2 IADL problems are from 7% to 8% more likely than those with no IADL problems to report higher preferences for routines. Nevertheless, preferences for routines were nonsignificant after controlling for cognitive variables. We could assume that both constructs of routinization and disability share in common psychological risk factors such as depression, anxiety, or cognitive impairment (Bergua et al., 2006), but they also remain associated independently of some variables, in particular, depression and anxiety. One common interpretation is that the highest level of performance for each IADL requires an elevated level of cognitive functioning for initiating and planning abilities in relatively unusual situations, as opposed to lower levels of functioning involving more automated processes (Artero, Touchon, & Ritchie, 2001; Barberger-Gateau et al., 1999a). The inability to completely control or master cognitively demanding tasks in older persons with mild cognitive impairments may, therefore, lead to activity restriction (Nourhashemi et al., 2001). The present results confirmed that IADL restriction was associated with cognitive functioning in particular in its executive components, which cancelled the effect of preferences for routines on IADL. The preferences for routines could be so explained by lower cognitive flexibility in the older adults, as shown by Tournier et al. (2012). Further longitudinal research is, however, needed to confirm these results, in particular in older persons suffering of cognitive disorders. An alternative interpretation is that the more vulnerable an older person is, in particular, in terms of depressive symptomatology, the more preferences for routines increase (Bergua et al., 2006; Bouisson, 2002), a phenomenon which may in turn restrict their level of performance of specific activities. However, the present results revealed an association between preferences for routines and IADL, independently of depressive symptomatology. Depression and preferences for routines would act as two independent processes leading to restriction in IADLs. According to the disablement process described by Verbrugge and Jette (1994), higher preferences for routines could so induce restriction in several IADLs, independently of sociodemographic, comorbidity, and psychological states. Preferences for routines could, therefore, be interpreted as an intraindividual factor reflecting poor adaptation to aging associated losses. Routines could lead to a kind of behavioral rigidity that responds to vulnerability in the emotional or cognitive domains. This hypothesis is consistent with the results of Zisberg et al. (2009) indicating a specific association of the functional IADL restriction with the fact of disliking disruption and not the fact of having routine. All of these results suggest that the fact that an association between the preferences for routines and IADLs could guide clinical intervention in reducing preferences for routines.

Model 2 = Model 1 + psychological variables (N = 207) PRS score Sociodemographic variables Female gender Age Education level Medication Psychological variables CESD score STAI score

1.01-1.15 2.31-13.80 1.15-1.45 0.10-0.61 0.97-1.26 1.02-1.14

1.07 5.64 1.29 0.24 1.10 1.07

4.29 14.36 18.06 9.07 2.11 6.32

0.03 0.46 0.06 0.47 0.07 0.03

0.07 1.73 0.26 –1.42 0.10 0.07

0.48 0.00* 0.01* 0.45 0.97 0.02*

0.96-1.08 1.73-7.34 1.03-1.26 0.30-1.71 0.89-1.12 1.01-1.12

1.02 3.56 1.14 0.72 1.00 1.06

0.49 11.87 6.33 0.56 0.001 5.04

0.37 0.05 0.45 0.06 0.03

1.27 0.13 –0.33 0.002 0.06

2.66-15.44 1.17-1.47 0.10-0.62 1.00-1.30

6.41 1.31 0.25 1.14 17.16 20.47 8.89 3.84 0.45 0.06 0.47 0.07

1.86 0.27 –1.39 0.13

0.00* 0.01* 0.44 0.56

2.00-8.27 1.04-1.28 0.30-1.69 0.92-1.16

4.07 1.16 0.71 1.03

15.03 7.81 0.59 0.34

0.36 0.05 0.44 0.06

0.03

1.02-1.16

95%CI

1.08

OR

6.03

Wald

0.03

SE1

0.08

b1

0.30

p-Value

0.97-1.09

95%CI

1.03

OR

1.08

Wald

0.03

SE1

No restriction versus restriction for two or more IADLS

0.02

Model 1 with sociodemographic variables (N = 207) 0.03 PRS score Sociodemographic variables 1.40 Female gender 0.14 Age –0.34 Education level 0.03 Medication

b1

No restriction versus restriction for one IADL

Table 4. Final Models of the Stepwise Multinomial Logistic Regressions Assessing the Specific Association between Routinization (PRS) and Different Activity Restriction Levels (IADL)

0.01*

0.00* 0.00* 0.00* 0.14

0.04*

0.00* 0.00* 0.00* 0.05*

0.01*

p-Value

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0.05 0.61 0.08 0.60 0.09 0.04

0.16 0.03

–0.005 2.23 0.23 –0.89 –0.03 0.11

–0.25 –0.13

0.99 0.00* 0.16 0.54 0.64 0.00*

0.01* 0.19

0.99-1.00 2.54-14.85 0.96-1.24 0.49-3.94 0.84-1.11 1.03-1.17

0.56-0.91 0.94-1.01

0.94 6.14 1.09 1.38 0.97 1.10

0.71 0.98

0.00 16.22 1.94 0.37 0.22 8.69

7.57 1.71

0.45 0.06 0.53 0.07 0.03

0.12 0.02

1.81 0.09 0.32 –0.03 0.09

–0.34 –0.02

0.15 0.03

–0.17 –0.13

0.02* 0.20

0.61-0.95 0.94-1.01

0.76 0.98

5.76 1.65

0.12 0.02

–0.28 –0.02

0.03

0.59 0.08 0.58 0.08

2.30 0.26 –0.90 0.04

0.00* 0.05* 0.58 0.78

3.09-17.18 1.00-1.28 0.48-3.61 0.89-1.16

7.29 1.13 1.32 1.02

20.61 3.72 0.30 0.08

0.44 0.06 0.51 0.07

1.99 0.12 0.28 0.02

0.00

0.04

0.02

0.46

0.96-1.09

1.02

0.55

0.03

0.02

*p < 0.05; **p < 0.01; ***p < 0.001; OR = Odds Ratios; CI = Confidence Intervals.

Model 4 with all significant covariates (N = 180) PRS score Sociodemographic variables Female gender Age Education level Medication Psychological variables CESD score STAI score Cognitive variables BVRT score IST score ZCT score

Model 3 = Model 1 + cognitive variables (N = 180) PRS score Sociodemographic variables Female gender Age Education level Medication Cognitive variables BVRT score IST score ZCT score

2.71 16.09

8.91

13.25 7.02 2.17 0.09

0.01

1.39 16.02

14.96 10.33 2.36 0.23

0.12 3.11-32.14 1.11-1.53 0.13-1.28 0.88-1.23

2.80-30.90 1.06-1.48 0.12-1.34 0.81-1.17

0.77 0.57-1.05 0.87 0.82-0.93

1.12 1.04-1.21

9.29 1.25 0.41 0.97

0.99 0.91-1.09

0.84 0.63-1.12 0.88 0.82-0.94

10.00 1.30 0.41 1.02

1.02 0.93-1.11

0.10 0.00*

0.00*

0.00* 0.01* 0.14 0.76

0.91

0.24 0.00*

0.00* 0.00* 0.12 0.63

0.73

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It remains to be clarified why preferences for routines are associated only multiple IADLs. For individuals with a single IADL restriction, we could hypothesize that preferences for routines remains moderate and constitutes a relatively adaptive coping strategy (Bergua et al., 2012). However, when at least 2 IADLs are restricted, the preferences for routines could become maladaptive and constitute a predictor of this functional restriction. Peres et al. (2008) demonstrated that IADL restriction for at least 2 IADLs increased the risk of progression to dementia 10 years before diagnosis. Therefore, preferences for routines could also represent a vulnerability factor in the preclinical phase of dementia. Further longitudinal research on this issue should clarify the impact of routinization in the dementia process. Another possible explanation for the association of multiple IADLs with routinization may concern the manner in which this construct is assessed, and in particular the diversity of items presented by the scale. As preferences for routines score of each participant is designed to reflect general attitudes toward stability or change for a range of daily life activities or circumstances, it is likely that participants who prefer stability for one activity prefer it for others. Moreover, if such preferences lead to a restriction of activities, it may explain the association of routines preferences across multiple IADL domains. The full examination of this question would likely require longitudinal designs with information concerning actual behaviors and activities in daily life. These findings should be so interpreted in light of specific methodological characteristics of the present study. First, the cross-sectional nature of analyses does not permit conclusions as to the direction of the observed associations. In addition, the findings are limited by the nature of the sample and cannot be generalized to pathological aging or dementia. Further studies are necessary to assess the contribution of preferences for routines to the disability process that is a risk for dementia. The PRS demonstrated a lower alpha coefficient in the present study than in the previous French validation study. This result constitutes a limitation and could be explained by the characteristics of samples studied. The current study is based on the elderly general population including very elderly adults (minimum age, 78 years), whereas previous studies included younger participants and clinical populations. Further research is, therefore, necessary to assess and improve the validity of this scale. The role of routines appears nonetheless to be an important question and can be understood relative to well-established associations between functional activities and certain individual characteristics or traits. The present findings indicate a link between functional restrictions for IADLs and preferences for routines. Further research is, however, needed to better understand the underlying mechanisms by which preferences for routines might moderate the impact of aging-related losses in the disablement process, and whether they may constitute a risk factor of further IADL restriction and dementia.

o o o o o o o o o o

o o o o o o o o o o

o o o o o o o o o o

o o o o o o o o o o

o o o o o o o o o o

1. Generally, I do the same things each day.

2. I am not happy to have to wait for someone.

3. I cannot stand to move things from their place.

4. I like unexpected events.

5. I do not like having to wait until it’s meal time.

6. I like to move and change activities.

7. I do not like having to change places for eating or watching television.

8. I prefer going to bed the same time every day.

9. I like going out to meet new people.

10. I like watching new programs or movies on television.

Almost always true

Usually true

Occasionally true

Usually not true

Almost never true

APPENDIX: Translation of French Preferences for Routinization Scale (Bouisson, 2002)

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Restriction in instrumental activities of daily living in older persons: association with preferences for routines and psychological vulnerability.

Disabilities in the Instrumental Activities of Daily Living (IADL) are frequently observed in older adults. A restriction in the daily life activities...
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