The Disablement model and Public health approach to Aging

재활의학과물리치료실

박관수

순서

1. Concept of disablement Model Nagi’s concept ICIDH concept

2. Public health approach to Aging 우리나라 노인문제 현황 공중보건 접근방법

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Understanding of the source of contemporary conceptual confusion Disablement Model

Nagi(1965) International Classification of Impairments,

Disabilities, and Handicaps(ICIDH-1)(WHO,1980) International Classification of functioning,

Disability and Health ICF (WHO,2000)

용어의 중복 각기 다른 협력 집단에서 각기 다른 model 의 개념을

사용

Nagi’s Concept of DisabilitySociologist Saad Nagi (1965)—Disability is

the expression of a physical or a mental limitation in a social context.

Social Security Act( 연방사회보장법 )- Disability as an inability to work due to a physical or mental impairment

Nagi 는 disability 를 사람의 능력과 social and physical environment 의 요구 사이의 gap 이라고 생각했다 (Nagi,1965,1976,1991).

PATHOLOGY IMPAIRMENTFUNCTIONAL LIMITATION DISABILITY

Definition

Measures

Interruption or interference of normal bodily processes or structures

Loss and/or abnormality of mental, emotional, physiological, or anatomical structure or function

Restriction or lack of ability to perform an action or activity in the manner or within the range considered normal for the person as a whole

Inability or limitation in performing socially defined activities and roles expected of individuals within a social and physical environment

Disease

Clinical pathology

Symptoms and signs

Pain

Balance, strength, range of motion (physical performance)

Locomotor activity (physical performance)

Mobility (survey)

Instrumental and activities of daily living (survey)

Level Cells and tissues

Organs and organ systems

Organism Society

Nagi’s Concept of Disability Disability is a limitation in performing

socially defined roles and tasks expected of an individual within a sociocultural and physical environment.

These roles and tasks are organized in spheres of life activities such as those of the family or other interpersonal relations Ex. work, employment, and other economic

pursuits; and education, recreation, and self-care

The concept of social roles 사회적 역할은 부모 , 노동자 , 대학교수 등과 같이

사회시스템에 어떻게 참여하는지에 따라 기본적으로 조직된다

Role is the organized system of participation of an individual in a social system

Tasks are specific activities through which the individual carries out his or her social roles. Nagi : Role 은 disability concept 의 한 부분으로 목적

있는 행동 , 조직적인 , 특별한 task 등으로 구성된다 .

Nagi’s Concept of Disability Not all impairments or functional

limitations precipitate disability, and similar patterns of disability may result from different types of impairments and limitations in function

Identical types of impairments and similar functional limitations may result in different patterns of disability

Nagi’s Concept of Disability Disability 의 severity 와 dimension

에 영향을 주는 요소 1. Limitation 에 처한 개인의 반응과 상황 2. 가족 , 친구 , 친지 , 고용주 , 동료 ,

서비스와 benefits 을 제공하는 조직과 전문가 등 타 인의 반응과 기대 3. 물리적 사회적 barrier 로부터 자유로운 정도와 환경적 특성 . (Nagi, 1991,)

Work Disability Two patient with Parkinson’s disease

두명 모두 rigidity, bradykinesia 가 있고 slow, shuffling gait, slow deliberate movement pattern 을 가지고 있다 .

One patient- restricted outside activities completely, 아침에 옷입는데 도움이 필요하고 대부분 TV 시청을 하면서 보내며 , depressed 되어 있으며 , 지속적으로 실업상태이다 .

The other patient- 대부분의 social life 에 참여하고 있으며 daily activity 는 배우자에 도움을 받고 있으며 , workplace modification 을 통해 종일 근무를 하고 있다 .

두 환자는 유사한 pathology, Impairment, functional limitation 을 가지고 있으나 매우 다른 work disability 를 가지고 있다 .

Disability 는 개인의 고유한 특성이라기 보다 개인과 환경의 상호작용에 의한 결과물이다

Nagi’s Disablement Model 의 발전

Verbrugge and Jette Nagi 의 disability 개념에 social role 을 첨가시킨다 .

Activities of daily living (ADL)-basic mobility 와 personal care 와 같은 behavior 을 포함한다 .

Instrumental activities of daily living (IADL) Preparing meals, doing housework, managing finances,

using the telephone, and shopping Paid and unpaid role activities

performing one’s occupation, parenting, grandparenting, and being s student.

Social activities attending church and other group activities and socializing

with friends and relatives Leisure activities participating in sport and physical

recreation, reading, or taking distant trips

Disability 에 영향을 미치는 외부 요인

Verbrugge & jette 은 social epidemiological 관점에서 3 가지 변수를 고려 해야 한다고 했다 .

Predisposing risk factor Intraindividual factors Extraindividual factors

1997 –add two important concepts to the Disablement model – concepts of secondary conditions and quality of life

Secondary condition 최초 disabling condition 의 이차적 결과로 나타나는

형태라고 정의했다 (1991, IOM report). Ex. pressure sores, contractures, depression, and

urinary tract infections 등이 포함된다 (Marge, 1988).

Secondary condition 은 pathology, impairment, functional limitation 혹은 additional disability 라고 할 수 있다고 했다 .

Enabling- Disabling process Disabling conditions not only develop

and progress but can be reversed through the application of rehabilitation and other forms of explicit intervention

Internal classification of Impairments, Disabilities, and Handicaps 1970’s Europe --> WHO, ICIDH(1980) ICF(2000)

Health conditions Impairments Disability (Activity limitation) Handicaps (Participation Restriction)

Impairment Impairment is any loss or abnormality of psychological,

physiological, or anatomical structure or function (WHO, 1980).

Impairment 는 ( 신체 일부의 심각한 변형이나 손실과 같은 ) 신체 기능 혹은 구조상의 이상을 의미한다 . (WHO, 2000)

ICF(ICIDH) 의 impairment 개념은 Nagi 의 impairment & pathology concept 을 포함

Nagi 의 impairment concept focus organs or organ system

ICF(ICIDH) impairment concept focus function and structure of the body and its component

Disability (Activity limitation) Disability is any restriction or lack (resulting from an

impairment) of ability to perform an activity in the manner or within the range considered normal for a human being (WHO, 1980)

Focus– activities carried out by the person

ICIDH disability 는 Nagi 의 functional limitation 과 disability 의 가교 역할

ICF 에서 disability 는 positive term 인 activity 로 바뀜

활동 (Activity) 은 개인에 의한 임무 또는 행동을 의미한다 . 활동제한 (Activitiy limitation) 은 개인이 활동을 할때 가질 수 있는

어려움을 의미한다 . Activities may be limited in nature, duration and quality (WHO,

2000).

Handicap(Participation restriction) Handicap is a disadvantage for a given individual,

resulting from an impairment or a disability, that limits or prevents the fulfillment of a role that is normal (depending on age, sex, and social and cultural factors) for that individual (WHO, 1980).

Nagi’s disability 의 role 개념을 포함하며 role 의 실재적인 수행보다는 Disadvantage 에 초점을 맞춘 것으로 문화적 규범을 반영한 사회 속의 사람에 초점을 맞추었다 .

참여 (Participation) 는 실질적인 생활 상황에의 연루를 의미한다 .

참여제약 (Participation restriction) 은 개인이 실질적인 생활 상황에 연루될 때 겪을 수 있는 문제를 의미한다 .

Participation may be restricted in nature, duration and quality (WHO, 2000).

Handicap(Participation restriction) Nagi’s disability 는 ICIDH 의 handicap & participation

은 본질적으로 같은 개념이다 .

Participation 은 사람의 건강상태 특히 impairments or disabilities 들과 사람이 살아가는 환경 사이의 복잡한 관계의 결과들이다

다른 환경은 같은 impairment 혹은 disability 를 가지고 있는 사람들에게 각기 다른 영향을 준다 .

Participation is therefore based on an ecological/environmental interaction model (WHO, 2000).

Directionality and the Dynamic nature of disability Static entities (Unidirectionl)

초기의 disablement model 은 ‘ disablement process 는 질병의 진행에 따라 단순이 한방향성을 가지는 진행이다’ 라는 전통적 생각을 가지고 있었다 (marge, 1988).

Dynamic Entities(Bidirection) Disablement 는 생애를 통해서 fluctuate 할

수 있다 . 최근에는 disablement process 는

downward- spiraling 한다고 보고 있다 .

Disablement concepts 과 quality of life 개념의 차이점

Quality of life 개념은 개인의 내적 상태 ,건강상태 뿐만 아니라 사회적 , 물리적 환경까지 고려하는 복잡한 개념이다 .

Quality of life 측정방법 삶의 질을 인지하는 개인 인식에 기초하는

주관적 방법 삶의 질의 외적 판단에 기초하는 객관적 방법

(Birren and Dieckermann, 1991)

Disablement concepts 과 quality of life 개념의 차이점

Quality of life 의 구성요소 (Lawton, 1983) Physiological Well-being Perceived quality of life Behavioral competence in multiple area( health, functional

health, cognition, time use, and social behavior) Objective environment

Most quality of life measures focus little attention on organ and body system functioning and focus more on the consequences of impairments at the personal activity or social role level.

Quality of life > Disability concept

Disablement concepts 과 quality of life 개념의 차이점

Modified Disablement Model

Modified Disablement Model

Patient Management

Disablement Model

Pathology Impairment

Functional Limitation

Self-Reported Disability

DiabetesLoss of lower-extremity sensibility

Altered performance in daily tasks

Disablement: ExamplesPathology Impairmen

tFunctionalLimitation

Disability

Sarcopenia

Loss of strength

Slow gait speed

Difficulty crossing street

Parkinson’s disease

Loss of balance

Tandem stand <10 sec

Difficulty with stairs

Alzheimer’s disease

Memory< age/educ norm

Inefficient, unsafe cooking,

Difficulty with meals

Functional Limitation 상태에서 Disability 를 예방 Change task demands (“demand”)

Simplify tasks (“change way you do the task”)

Reduce frequency of task (“do less often”) Recruit spared areas of ability to

compensate for deficit (“supply”) Use alternative muscle groups Organize activity efficiently to overcome

weakness or other motor or sensory deficits

Reduce Disability: Change Task Demands

Pathology Impairment

Functional Limitation

Self-Reported Disability

SarcopeniaLoss of lower-extremity strength

Altered performance in daily tasks

Do less frequently, change environment