Health conditions, functional status and health care utilization in adults with cerebral palsy

Health conditions, functional status and health care utilization in adults with cerebral palsy Abstract Aim Health conditions in children with cerebral palsy (CP) are well described, yet health is less defined with advancing age. We examined health conditions, functional status and health care utilization in adults with CP across age groups. Methods We collected cross-sectional data on health conditions, functional status and utilization from the medical records of adults with CP across a large university-affiliated primary care network using the Rochester Health Status Survey IV (RHSS-IV), a 58-item validated survey. Data from the National Health and Nutrition Examination Survey and National Health Interview Survey provided prevalence estimates for the general population as comparison. Results Compared to the general population, adults with CP had higher rates of seizure disorder, obesity and asthma across all ages. Adults with CP under 30 years of age had higher rates of hypertension (16.7 versus 5.6%; P = 0.04), urinary incontinence (41.7 versus 10.5%; P < 0.001) and depression (16.7 versus 6.9%; P = 0.07). Conversely, there were lower rates of alcohol misuse, tobacco/nicotine and sexually transmitted illnesses. Independence with all activities of daily living decreased from 37.5% at 18–29 years of age to 22.5% in those 60 and over. Seizure disorders, urinary incontinence and gastroesophageal reflux disease were all independently associated with lower functional status. As expected, health care utilization increased with advancing age. Conclusions Adults with CP should be monitored for conditions occurring at higher prevalence in CP, as well as common conditions occurring with advancing age. Age-related functional decline should be anticipated, especially with coexisting seizure disorders and urinary incontinence. Access to care, aging, chronic disease, developmental disabilities, motor development, cerebral palsy Introduction Cerebral palsy (CP) is a neurodevelopmental condition characterized by abnormal muscle tone, spasticity and altered posture. CP is caused by a heterogeneous range of abnormalities in the developing brain and affects between 1.5 and 4 patients per 1000 births (1–5). Advances in medical care have resulted in increasing life expectancy of people with CP, with many living into later adulthood (6,7). Many of these adults are living in community settings and, in turn, receive their health care in traditional primary care settings. Therefore, it is important that primary care physicians (PCPs) are equipped to care for adults with CP, including recognizing comorbid medical conditions associated with aging. Although health conditions in children with CP are well described, health conditions, functional status and health care utilization remain less defined with advancing age (8). The most commonly reported health conditions in adults with CP involve increasing musculoskeletal impairments, fatigue, pain, seizures, intellectual disabilities and osteoporosis (2,9–16). Functional decline and associations among chronic disease in adults with CP has been described (10,17,18), but the influence of medical conditions on functional status has not been explored (19). It is also important to understand how adults with CP access health care. Prior evidence has suggested that individuals with developmental disabilities receive less preventive care and utilize the emergency department (ED) at higher rates due to barriers to care (20–23), but little evidence exists around utilization patterns specific to adults with CP. To advance our clinical understanding of adults with CP, this study aimed to (i) examine the health conditions and functional status in adults with CP across age groups; (ii) identify factors associated with walking and activities of daily living; and (iii) explore health care utilization by adults with CP. Methods CP subject identification and age groups Adults with CP were identified throughout a large university-affiliated primary care network of 35 practices across 5 counties in Western upstate New York. Adults with CP were identified based on a query of the electronic health record using the International Classification of Diseases, Ninth Revision (ICD-9) codes of 343.xx on the problem list (24). The diagnosis of CP was established through direct chart review prior to manual data abstraction. The sample was divided into five age groups to investigate health status associated with age, consistent with similar literature (25,26). The five age groups were comprised of participants aged 18–29, 30–39, 40–49, 50–59 and >59 years. Rochester health status survey (RHSS) Cross-sectional data were collected from the medical records of adults with CP aged 18 years and over using the Rochester Health Status Survey IV (RHSS-IV). The RHSS-IV is a 58-item validated survey of health and functional status in adults with intellectual or developmental disabilities (IDD) (27). It was originally developed to support broad health services research and is composed of five sections (i) demographics, (ii) general health status, (iii) medical conditions, (iv) functional status and (v) health services utilization. The RHSS-IV was designed to examine a wide range of developmental conditions, including CP. However, information specific to CP, such as topographic type of CP, presence and degree of hypertonia (spasticity, dystonia, mixed) or Gross Motor Function Classification System (GMFCS) level were not available on the RHSS-IV. RHSS data abstraction Data abstraction closely followed procedures defined as optimal in the RHSS validation study (27). A nurse with specialization in physical disabilities collected data manually through chart review. Health conditions were identified from the problem list and past medical history. Data abstraction and chart review averaged about 60 min per record. Chart reviewed included an in-depth appraisal of notes and documentation from the PCP, physical therapist, occupational therapist, sub-specialists (e.g. physical medicine and rehabilitation physicians, orthopaedists, neurologists, gastroenterologists, urologists) and mental health therapists. The principal investigator, a physician with expertise in intellectual and developmental disabilities, oversaw the chart review process and was consulted for any questions pertaining to data collection. All data were double entered using Microsoft Access and the two datasets were then compared using SAS version 9.4. Any discrepancies in data entry were resolved using the paper survey. RHSS-IV variable creation Health conditions in the following broad categories were collected: heart and circulatory diseases, pulmonary diseases, endocrine/metabolic diseases, gastrointestinal diseases, neurologic diseases, genito-urinary and kidney diseases and musculoskeletal conditions. Functional ability was examined based on the ability to perform activities of daily living (ADLs) and the person’s level of walking independence. ADL’s were recorded as (i) independent, (ii) requiring supervision or verbal prompt, (iii) requiring physical assistance or (iv) totally dependent. Binary groups were subsequently created, one that was totally independent with ADLs and a second that required any amount of assistance. Walking was recorded as (i) walks independently in all settings; (ii) walks independently or with assistive device(s) in most settings; (iii) walks independently or with assistive device(s) in some settings and (iv) cannot walk independently or with assistive device(s) in any settings. Walking was dichotomized as ‘independent/mostly independent’ versus ‘non-ambulatory /some ambulation with assistance.’ Specific IQ was not available for the majority of records. Intellectual capacity was determined based on whether an intellectual disability was noted in the chart (yes/no). National health and nutrition examination survey (NHANES) and National health interview survey (NHIS) We used population-level data to serve as a point of reference for comparison to rates observed within adults with CP. Both NHANES and NHIS are national surveys administered by the National Center for Health Statistics (NCHS) and the Centers for Disease Control and Prevention (CDC). NHANES utilizes a multistage probability design that combines interviews and physical examinations to assess the health and nutritional status of the United States population in 2-year cycles. NHIS is a household-based survey designed to monitor the prevalence of a broad range of health conditions. Two cycles of NHANES (2011–2012, 2013–2014) were used to establish the prevalence of all health conditions except seizure and migraines, which were not contained within the NHANES datasets. Data on constipation were obtained from the 2009–2010 NHANES cycle. The NHIS 2015 dataset was used to estimate the prevalence of seizures and migraines in the general population. The data presented from NHANES and NHIS represents broad US population data, including those with CP. NHANES and NHIS variable creation The data abstracted from NHANES were based upon the question ‘Has a doctor or health professional ever told you that you had or have…?’ Tobacco/nicotine misuse was defined as using tobacco or nicotine within the last 5 days. Alcohol misuse was defined based on the question ‘Was there ever a time or times in your life when you drank four or more drinks of any kind of alcoholic beverage almost every day?’ Depression was determined by assessing variables in NHANES using the Patient Health Questionnaire (PHQ-9). The PHQ-9 is a validated, nine-item screening instrument that inquires about symptoms of depression on a scale of 0 to 3 (28). Consistent with prior literature and clinical practice, a score of 10 or higher was used to define depression (29). Statistical analysis All statistical analyses were carried out using SAS version 9.4 (SAS Institute Inc., Cary, NC). Within the RHSS sample of individuals with CP, confidence intervals around the point prevalence of health conditions were calculated using the Clopper–Pearson method (30,31). We calculated the point prevalence of health conditions in our national samples from NHANES and NHIS using survey function procedures to account for the multistage probability sampling design. The prevalence rates of health conditions in adults with CP were compared to the general population. To account for the difference in the survey methodology between the RHSS-IV, NHANES and NHIS, the prevalence rates were compared based on the difference in proportion and the calculated z-scores based on the variance. The difference between the two proportions was calculated along with the estimated standard errors for this difference. The difference was then normalized by using the estimated standard error to obtain a z-score. The z-score was then converted to a P-value for a two-tailed test by finding the probability of z. Logistic regression models were used to examine trends in prevalence in adults with CP across age groups while adjusting for gender. We compared proportions with chi-square test statistics for proportions and the Cochran–Armitage test for ordered proportions. Multivariate logistic regression models were used to examine the independent factors associated with walking and ADL status in two separate regression models. The dependent variables for the two regressions were (i) independence with all ADLs (eating, dressing, bathing, toileting) (yes/no); and (ii) independence or mostly independent with walking (yes/no). The independent variables included in the regression based on clinical significance were age group, gender and intellectual disability (yes/no). Health conditions were included in the model if their bivariate comparison showed a P value of less than or equal to 0.2. Human subjects/institutional review board review This study was approved by the University of Rochester Research Subjects Review Board and the protocols used by NHANES and NHIS were approved by the National Center for Health Statistics (NCHS) Institutional Review Board. Results Our sample of 229 adults with CP included a broad age distribution. A total of 24.5% (N = 56) of adults were ≤29 years of age, 17.9% (N = 41) were between 30 and 39 years, 22.7% (N = 51) were between 40 and 49 years, 17.9% (N = 41) were between 50 and 59 years and 17.5% (N = 40) were 60 years of age or over. The sample was predominantly (59.0%; N = 135) male and the majority (54.1%; N = 124) had an intellectual disability. Within this sample 44.1% (N = 101) lived in a supervised setting (i.e. group home), 39.3% (N = 90) lived with family and 16.6% (N = 38) were independent. Table 1 illustrates the point prevalence of health conditions in our cohort of adults with CP compared to data from NHANES and NHIS (‘the general population’). Compared to the general population, adults with CP had higher rates of seizure disorder, obesity and asthma across all ages. Adults with CP under 30 years of age had higher rates of hypertension (16.7 versus 5.6%; P = 0.04), urinary incontinence (41.7 versus 10.5%; P < 0.001) and depression (16.7 versus 6.9%; P = 0.07) compared to the general population. Adults with CP also had a higher prevalence of depression across all ages; but this finding was not consistently significant by age group. Adults with CP had a higher prevalence of hypertension across most age groups, except in the 30–39 year age group. In contrast, they demonstrated lower rates of alcohol misuse, tobacco/nicotine and sexually transmitted illnesses (STIs) compared to the general population. Table 1. Health conditions in adults with CP and in the general population from the RHSS-IV and National Health and Nutrition Examination Surveya 2011–2014 Health condition  18–29 years  30–39 years  40–49 years  50–59 years  >59 years  CPb (N = 56)  General populationa  P-Value  CPb (N = 41)  General populationa  P-Value  CPb (N = 51)  General populationa  P-Value  CPb (N = 41)  General populationb  P-Value  CPb (N = 40)  General populationa  P-Value  Neurologic   Seizure disorderc  44.6%  2.5%  <0.001  56.1%  2.0%  <0.001  39.2%  1.6%  <0.001  39.0%  2.3%  <0.001  30.0%  1.5%  <0.001   Migraine/severe Headachec  16.1%  17.1%  0.93  26.8%  19.4%  0.28  17.7%  18.0%  0.95  14.6%  15.8%  0.83  5.0%  8.2%  0.35  Gastrointestinal   Constipationd  3.6%  17.1%  <0.001  4.9%  23.9%  <0.001  2.0%  22.5%  <0.001  7.3%  77.5%  <0.001  5.0%  74.8%  <0.001   GERD  41.1%  —  —  34.1%  —  —  41.2%  —  —  39.0%  —  —  57.5%  —  —   Bowel obstruction  5.4%  —  —  4.9%  —  —  3.9%  —  —  2.4%  —  —  2.5%  —  —  Psychiatric   Depressione  16.1%  6.9%  0.07  17.1%  7.8%  0.13  37.3%  10.1%  <0.001  19.5%  10.2%  0.14  27.5%  5.7%  0.002   Anxiety disorder  7.1%  f  —  14.6%  f  —  23.5%  f  —  22.2%  f  —  16.7%  f  —   ADHD  8.9%  —  —  4.9%  —  —  2.0%  —  —  7.3%  —  —  0.0%  —  —   Schizophrenia/psychosis  1.8%  g  —  0.0%  g    2.0%  g  —  4.9%  g  —  10.0%  g  —  Heart and circulatory   Hypertension  16.1%  5.6%  0.04  12.2%  16.1%  0.47  37.3%  26.0%  0.11  48.8%  40.8%  0.33  80.0%  58.4%  0.001   Hyperlipidemia  7.1%  6.3%  0.82  0.0%  16.3%  <.001  23.5%  32.5%  0.17  29.3%  46.7%  0.02  45.0%  53.4%  0.29   Myocardial Infarction or  stroke  5.4%  0.6%  0.11  2.4%  0.7%  0.47  9.8%  1.9%  0.06  7.3%  5.5%  0.66  22.5%  14.8%  0.25  Pulmonary   Asthma  35.7%  18.4%  0.01  58.5%  14.0%  <0.001  60.8%  15.3%  <0.001  43.9%  12.4%  <0.001  45.0%  13.5%  <0.001   Allergies  37.5%  21.2%  0.03  48.8%  30.1%  0.11  58.8%  45.3%  0.13  39.0%  48.8%  0.29  42.5%  37.0%  0.55   COPDh  0.0%  0.2%  0.05  0.0%  0.4%  0.05  2.0%  1.5%  0.83  4.9%  4.8%  0.99  7.5%  7.7%  0.96  Endocrine   Diabetes  7.1%  0.5%  0.05  4.9%  2.4%  0.47  3.9%  6.5%  0.39  9.8%  12.3%  0.60  12.5%  19.1%  0.23   Hypothyroidi  7.1%  3.5%  0.30  9.8%  4.5%  0.26  9.8%  9.6%  0.97  17.1%  12.3%  0.43  17.5%  18.8%  0.84   Hyperthyroid  0.0%      0.0%      2.0%      0.0%      2.5%      Genito-urinary and kidney   Urinary incontinence  41.1%  10.5%  <0.001  43.9%  14.7%  <0.001  45.1%  25.8%  0.01  39.0%  33.2%  0.46  55.0%  42.5%  0.12   Chronic kidney disease  1.8%  1.1%  0.68  0.0%  1.9%  <0.001  3.9%  1.9%  0.46  2.4%  3.6%  0.70  0.9%  4.7%  0.94  Musculoskeletal   Osteoporosisj  10.7%  —  —  24.4%  —  —  9.8%  2.4%  0.08  22.0%  5.7%  0.01  8.3%  14.2%  <0.001  Substance use                                 Tobacco/nicotinek  3.6%  21.8%  <0.001  4.9%  26.3%  <0.001  11.8%  31.2%  <0.001  12.2%  26.9%  0.01  1.8%  13.3%  0.50   Alcohol misusel  0.0%  9.9%  <0.001  0.0%  15.6%  <0.001  0.0%  19.2%  <0.001  4.9%  19.3%  <0.001  2.5%  13.5%  <0.001  Infectious   STIm  1.8%  7.0%  0.02  9.8%  7.1%  0.58  3.9%  6.5%  0.40  4.9%  7.1%  0.56  2.5%  —  —  General   Obesity  37.5%  15.0%  <0.001  43.9%  31.8%  <0.001  47.1%  38.1%  <0.001  46.3%  40.8%  <0.001  37.5%  35.4%  <0.001  Health condition  18–29 years  30–39 years  40–49 years  50–59 years  >59 years  CPb (N = 56)  General populationa  P-Value  CPb (N = 41)  General populationa  P-Value  CPb (N = 51)  General populationa  P-Value  CPb (N = 41)  General populationb  P-Value  CPb (N = 40)  General populationa  P-Value  Neurologic   Seizure disorderc  44.6%  2.5%  <0.001  56.1%  2.0%  <0.001  39.2%  1.6%  <0.001  39.0%  2.3%  <0.001  30.0%  1.5%  <0.001   Migraine/severe Headachec  16.1%  17.1%  0.93  26.8%  19.4%  0.28  17.7%  18.0%  0.95  14.6%  15.8%  0.83  5.0%  8.2%  0.35  Gastrointestinal   Constipationd  3.6%  17.1%  <0.001  4.9%  23.9%  <0.001  2.0%  22.5%  <0.001  7.3%  77.5%  <0.001  5.0%  74.8%  <0.001   GERD  41.1%  —  —  34.1%  —  —  41.2%  —  —  39.0%  —  —  57.5%  —  —   Bowel obstruction  5.4%  —  —  4.9%  —  —  3.9%  —  —  2.4%  —  —  2.5%  —  —  Psychiatric   Depressione  16.1%  6.9%  0.07  17.1%  7.8%  0.13  37.3%  10.1%  <0.001  19.5%  10.2%  0.14  27.5%  5.7%  0.002   Anxiety disorder  7.1%  f  —  14.6%  f  —  23.5%  f  —  22.2%  f  —  16.7%  f  —   ADHD  8.9%  —  —  4.9%  —  —  2.0%  —  —  7.3%  —  —  0.0%  —  —   Schizophrenia/psychosis  1.8%  g  —  0.0%  g    2.0%  g  —  4.9%  g  —  10.0%  g  —  Heart and circulatory   Hypertension  16.1%  5.6%  0.04  12.2%  16.1%  0.47  37.3%  26.0%  0.11  48.8%  40.8%  0.33  80.0%  58.4%  0.001   Hyperlipidemia  7.1%  6.3%  0.82  0.0%  16.3%  <.001  23.5%  32.5%  0.17  29.3%  46.7%  0.02  45.0%  53.4%  0.29   Myocardial Infarction or  stroke  5.4%  0.6%  0.11  2.4%  0.7%  0.47  9.8%  1.9%  0.06  7.3%  5.5%  0.66  22.5%  14.8%  0.25  Pulmonary   Asthma  35.7%  18.4%  0.01  58.5%  14.0%  <0.001  60.8%  15.3%  <0.001  43.9%  12.4%  <0.001  45.0%  13.5%  <0.001   Allergies  37.5%  21.2%  0.03  48.8%  30.1%  0.11  58.8%  45.3%  0.13  39.0%  48.8%  0.29  42.5%  37.0%  0.55   COPDh  0.0%  0.2%  0.05  0.0%  0.4%  0.05  2.0%  1.5%  0.83  4.9%  4.8%  0.99  7.5%  7.7%  0.96  Endocrine   Diabetes  7.1%  0.5%  0.05  4.9%  2.4%  0.47  3.9%  6.5%  0.39  9.8%  12.3%  0.60  12.5%  19.1%  0.23   Hypothyroidi  7.1%  3.5%  0.30  9.8%  4.5%  0.26  9.8%  9.6%  0.97  17.1%  12.3%  0.43  17.5%  18.8%  0.84   Hyperthyroid  0.0%      0.0%      2.0%      0.0%      2.5%      Genito-urinary and kidney   Urinary incontinence  41.1%  10.5%  <0.001  43.9%  14.7%  <0.001  45.1%  25.8%  0.01  39.0%  33.2%  0.46  55.0%  42.5%  0.12   Chronic kidney disease  1.8%  1.1%  0.68  0.0%  1.9%  <0.001  3.9%  1.9%  0.46  2.4%  3.6%  0.70  0.9%  4.7%  0.94  Musculoskeletal   Osteoporosisj  10.7%  —  —  24.4%  —  —  9.8%  2.4%  0.08  22.0%  5.7%  0.01  8.3%  14.2%  <0.001  Substance use                                 Tobacco/nicotinek  3.6%  21.8%  <0.001  4.9%  26.3%  <0.001  11.8%  31.2%  <0.001  12.2%  26.9%  0.01  1.8%  13.3%  0.50   Alcohol misusel  0.0%  9.9%  <0.001  0.0%  15.6%  <0.001  0.0%  19.2%  <0.001  4.9%  19.3%  <0.001  2.5%  13.5%  <0.001  Infectious   STIm  1.8%  7.0%  0.02  9.8%  7.1%  0.58  3.9%  6.5%  0.40  4.9%  7.1%  0.56  2.5%  —  —  General   Obesity  37.5%  15.0%  <0.001  43.9%  31.8%  <0.001  47.1%  38.1%  <0.001  46.3%  40.8%  <0.001  37.5%  35.4%  <0.001  The bold indicates statistical significance. ADHD, attention deficit hyperactivity disorder; COPD, chronic obstructive lung disease; GERD, gastroesophageal disease; STI, indicates sexually transmitted illness. aAll data are from NHANES 2011–2012 and 2013–2014 unless otherwise specified. bConfidence intervals obtained using the Clopper–Pearson method due to small sample size. cData in general population data from NHIS. dData in general population from NHANES 2009–2010. eDepression in general population defined as having a PHQ-9 score of 10 or greater. MEC weights used to calculate weights estimates. fThe 12-month prevalence of generalized anxiety disorder among adults is estimated to be 2.9% In the United States. The lifetime risk for generalized anxiety disorder is estimated at 9.0%. gThe lifetime prevalence of schizophrenia ranges between 0.18 and 1.5%, with a mean report prevalence of 0.5% (32,33). hData for general population from NHANES 2013–2014 only. iData for general population includes any thyroid problem. jData from NHANES 2013–2014 only, questions only asked for persons aged 40 and above. kDefined in general population as tobacco or nicotine use in the last 5 days. lDefined in general population as drinking five or more drinks per day almost every day mDefined in general population as having gonorrhea, chlamydia or genital herpes in the past 12 month. View Large Table 1. Health conditions in adults with CP and in the general population from the RHSS-IV and National Health and Nutrition Examination Surveya 2011–2014 Health condition  18–29 years  30–39 years  40–49 years  50–59 years  >59 years  CPb (N = 56)  General populationa  P-Value  CPb (N = 41)  General populationa  P-Value  CPb (N = 51)  General populationa  P-Value  CPb (N = 41)  General populationb  P-Value  CPb (N = 40)  General populationa  P-Value  Neurologic   Seizure disorderc  44.6%  2.5%  <0.001  56.1%  2.0%  <0.001  39.2%  1.6%  <0.001  39.0%  2.3%  <0.001  30.0%  1.5%  <0.001   Migraine/severe Headachec  16.1%  17.1%  0.93  26.8%  19.4%  0.28  17.7%  18.0%  0.95  14.6%  15.8%  0.83  5.0%  8.2%  0.35  Gastrointestinal   Constipationd  3.6%  17.1%  <0.001  4.9%  23.9%  <0.001  2.0%  22.5%  <0.001  7.3%  77.5%  <0.001  5.0%  74.8%  <0.001   GERD  41.1%  —  —  34.1%  —  —  41.2%  —  —  39.0%  —  —  57.5%  —  —   Bowel obstruction  5.4%  —  —  4.9%  —  —  3.9%  —  —  2.4%  —  —  2.5%  —  —  Psychiatric   Depressione  16.1%  6.9%  0.07  17.1%  7.8%  0.13  37.3%  10.1%  <0.001  19.5%  10.2%  0.14  27.5%  5.7%  0.002   Anxiety disorder  7.1%  f  —  14.6%  f  —  23.5%  f  —  22.2%  f  —  16.7%  f  —   ADHD  8.9%  —  —  4.9%  —  —  2.0%  —  —  7.3%  —  —  0.0%  —  —   Schizophrenia/psychosis  1.8%  g  —  0.0%  g    2.0%  g  —  4.9%  g  —  10.0%  g  —  Heart and circulatory   Hypertension  16.1%  5.6%  0.04  12.2%  16.1%  0.47  37.3%  26.0%  0.11  48.8%  40.8%  0.33  80.0%  58.4%  0.001   Hyperlipidemia  7.1%  6.3%  0.82  0.0%  16.3%  <.001  23.5%  32.5%  0.17  29.3%  46.7%  0.02  45.0%  53.4%  0.29   Myocardial Infarction or  stroke  5.4%  0.6%  0.11  2.4%  0.7%  0.47  9.8%  1.9%  0.06  7.3%  5.5%  0.66  22.5%  14.8%  0.25  Pulmonary   Asthma  35.7%  18.4%  0.01  58.5%  14.0%  <0.001  60.8%  15.3%  <0.001  43.9%  12.4%  <0.001  45.0%  13.5%  <0.001   Allergies  37.5%  21.2%  0.03  48.8%  30.1%  0.11  58.8%  45.3%  0.13  39.0%  48.8%  0.29  42.5%  37.0%  0.55   COPDh  0.0%  0.2%  0.05  0.0%  0.4%  0.05  2.0%  1.5%  0.83  4.9%  4.8%  0.99  7.5%  7.7%  0.96  Endocrine   Diabetes  7.1%  0.5%  0.05  4.9%  2.4%  0.47  3.9%  6.5%  0.39  9.8%  12.3%  0.60  12.5%  19.1%  0.23   Hypothyroidi  7.1%  3.5%  0.30  9.8%  4.5%  0.26  9.8%  9.6%  0.97  17.1%  12.3%  0.43  17.5%  18.8%  0.84   Hyperthyroid  0.0%      0.0%      2.0%      0.0%      2.5%      Genito-urinary and kidney   Urinary incontinence  41.1%  10.5%  <0.001  43.9%  14.7%  <0.001  45.1%  25.8%  0.01  39.0%  33.2%  0.46  55.0%  42.5%  0.12   Chronic kidney disease  1.8%  1.1%  0.68  0.0%  1.9%  <0.001  3.9%  1.9%  0.46  2.4%  3.6%  0.70  0.9%  4.7%  0.94  Musculoskeletal   Osteoporosisj  10.7%  —  —  24.4%  —  —  9.8%  2.4%  0.08  22.0%  5.7%  0.01  8.3%  14.2%  <0.001  Substance use                                 Tobacco/nicotinek  3.6%  21.8%  <0.001  4.9%  26.3%  <0.001  11.8%  31.2%  <0.001  12.2%  26.9%  0.01  1.8%  13.3%  0.50   Alcohol misusel  0.0%  9.9%  <0.001  0.0%  15.6%  <0.001  0.0%  19.2%  <0.001  4.9%  19.3%  <0.001  2.5%  13.5%  <0.001  Infectious   STIm  1.8%  7.0%  0.02  9.8%  7.1%  0.58  3.9%  6.5%  0.40  4.9%  7.1%  0.56  2.5%  —  —  General   Obesity  37.5%  15.0%  <0.001  43.9%  31.8%  <0.001  47.1%  38.1%  <0.001  46.3%  40.8%  <0.001  37.5%  35.4%  <0.001  Health condition  18–29 years  30–39 years  40–49 years  50–59 years  >59 years  CPb (N = 56)  General populationa  P-Value  CPb (N = 41)  General populationa  P-Value  CPb (N = 51)  General populationa  P-Value  CPb (N = 41)  General populationb  P-Value  CPb (N = 40)  General populationa  P-Value  Neurologic   Seizure disorderc  44.6%  2.5%  <0.001  56.1%  2.0%  <0.001  39.2%  1.6%  <0.001  39.0%  2.3%  <0.001  30.0%  1.5%  <0.001   Migraine/severe Headachec  16.1%  17.1%  0.93  26.8%  19.4%  0.28  17.7%  18.0%  0.95  14.6%  15.8%  0.83  5.0%  8.2%  0.35  Gastrointestinal   Constipationd  3.6%  17.1%  <0.001  4.9%  23.9%  <0.001  2.0%  22.5%  <0.001  7.3%  77.5%  <0.001  5.0%  74.8%  <0.001   GERD  41.1%  —  —  34.1%  —  —  41.2%  —  —  39.0%  —  —  57.5%  —  —   Bowel obstruction  5.4%  —  —  4.9%  —  —  3.9%  —  —  2.4%  —  —  2.5%  —  —  Psychiatric   Depressione  16.1%  6.9%  0.07  17.1%  7.8%  0.13  37.3%  10.1%  <0.001  19.5%  10.2%  0.14  27.5%  5.7%  0.002   Anxiety disorder  7.1%  f  —  14.6%  f  —  23.5%  f  —  22.2%  f  —  16.7%  f  —   ADHD  8.9%  —  —  4.9%  —  —  2.0%  —  —  7.3%  —  —  0.0%  —  —   Schizophrenia/psychosis  1.8%  g  —  0.0%  g    2.0%  g  —  4.9%  g  —  10.0%  g  —  Heart and circulatory   Hypertension  16.1%  5.6%  0.04  12.2%  16.1%  0.47  37.3%  26.0%  0.11  48.8%  40.8%  0.33  80.0%  58.4%  0.001   Hyperlipidemia  7.1%  6.3%  0.82  0.0%  16.3%  <.001  23.5%  32.5%  0.17  29.3%  46.7%  0.02  45.0%  53.4%  0.29   Myocardial Infarction or  stroke  5.4%  0.6%  0.11  2.4%  0.7%  0.47  9.8%  1.9%  0.06  7.3%  5.5%  0.66  22.5%  14.8%  0.25  Pulmonary   Asthma  35.7%  18.4%  0.01  58.5%  14.0%  <0.001  60.8%  15.3%  <0.001  43.9%  12.4%  <0.001  45.0%  13.5%  <0.001   Allergies  37.5%  21.2%  0.03  48.8%  30.1%  0.11  58.8%  45.3%  0.13  39.0%  48.8%  0.29  42.5%  37.0%  0.55   COPDh  0.0%  0.2%  0.05  0.0%  0.4%  0.05  2.0%  1.5%  0.83  4.9%  4.8%  0.99  7.5%  7.7%  0.96  Endocrine   Diabetes  7.1%  0.5%  0.05  4.9%  2.4%  0.47  3.9%  6.5%  0.39  9.8%  12.3%  0.60  12.5%  19.1%  0.23   Hypothyroidi  7.1%  3.5%  0.30  9.8%  4.5%  0.26  9.8%  9.6%  0.97  17.1%  12.3%  0.43  17.5%  18.8%  0.84   Hyperthyroid  0.0%      0.0%      2.0%      0.0%      2.5%      Genito-urinary and kidney   Urinary incontinence  41.1%  10.5%  <0.001  43.9%  14.7%  <0.001  45.1%  25.8%  0.01  39.0%  33.2%  0.46  55.0%  42.5%  0.12   Chronic kidney disease  1.8%  1.1%  0.68  0.0%  1.9%  <0.001  3.9%  1.9%  0.46  2.4%  3.6%  0.70  0.9%  4.7%  0.94  Musculoskeletal   Osteoporosisj  10.7%  —  —  24.4%  —  —  9.8%  2.4%  0.08  22.0%  5.7%  0.01  8.3%  14.2%  <0.001  Substance use                                 Tobacco/nicotinek  3.6%  21.8%  <0.001  4.9%  26.3%  <0.001  11.8%  31.2%  <0.001  12.2%  26.9%  0.01  1.8%  13.3%  0.50   Alcohol misusel  0.0%  9.9%  <0.001  0.0%  15.6%  <0.001  0.0%  19.2%  <0.001  4.9%  19.3%  <0.001  2.5%  13.5%  <0.001  Infectious   STIm  1.8%  7.0%  0.02  9.8%  7.1%  0.58  3.9%  6.5%  0.40  4.9%  7.1%  0.56  2.5%  —  —  General   Obesity  37.5%  15.0%  <0.001  43.9%  31.8%  <0.001  47.1%  38.1%  <0.001  46.3%  40.8%  <0.001  37.5%  35.4%  <0.001  The bold indicates statistical significance. ADHD, attention deficit hyperactivity disorder; COPD, chronic obstructive lung disease; GERD, gastroesophageal disease; STI, indicates sexually transmitted illness. aAll data are from NHANES 2011–2012 and 2013–2014 unless otherwise specified. bConfidence intervals obtained using the Clopper–Pearson method due to small sample size. cData in general population data from NHIS. dData in general population from NHANES 2009–2010. eDepression in general population defined as having a PHQ-9 score of 10 or greater. MEC weights used to calculate weights estimates. fThe 12-month prevalence of generalized anxiety disorder among adults is estimated to be 2.9% In the United States. The lifetime risk for generalized anxiety disorder is estimated at 9.0%. gThe lifetime prevalence of schizophrenia ranges between 0.18 and 1.5%, with a mean report prevalence of 0.5% (32,33). hData for general population from NHANES 2013–2014 only. iData for general population includes any thyroid problem. jData from NHANES 2013–2014 only, questions only asked for persons aged 40 and above. kDefined in general population as tobacco or nicotine use in the last 5 days. lDefined in general population as drinking five or more drinks per day almost every day mDefined in general population as having gonorrhea, chlamydia or genital herpes in the past 12 month. View Large Table 2 depicts the trend in the prevalence of health conditions across the different age groups. Seizure disorder, constipation and depression remained consistent across age groups. The prevalence of hypertension, hyperlipidemia and osteoporosis increased across all age groups. Compared to younger adults aged 18–29, adults over the age of 59 with CP had a substantially greater prevalence of hypertension (AOR 23.2; 95% CI 7.9–67.9), hyperlipidemia (AOR 10.5; 95% CI 3.2–34.7) and osteoporosis (AOR7.9; 95% CI 2.7–22.6). Table 2. Health conditions across age groups in adults with CP from the RHSS-IV 2011–2014 Outcome  18–29 years AORa (N = 56)  30–39 years AORa (N = 41)  40–49 years AORa (N = 51)  50–59 years AORa (N = 41)  ≥60 years AORa (N = 40)  Neurologic   Seizure disorder (N = 96)  1.0  1.6 (0.7–3.6)  0.8 (0.4–1.7)  0.8 (0.3–1.7)  0.5 (0.2–1.2)   Migraine/severe headache (N = 37)  1.0  2.0 (0.7–5.4)  1.2 (0.4–3.2)  0.9 (0.3–2.8)  0.3 (0.06–1.4)  Psychiatric   Depression (N = 54)  1.0  1.1 (0.4–3.3)  3.4 (1.3–8.6)  1.3 (0.5–3.8)  2.2 (0.8–6.2)   Anxiety disorder (N = 36)  1.0  2.3 (0.6–8.6)  4.1 (1.2–13.6)  3.2 (0.9–11.5)  2.4 (0.6–9.1)  Heart and circulatory   MI or stroke (N = 21)  1.0  0.4 (0.05–4.5)  2.0 (0.4–8.6)  1.4 (0.3–7.4)  5.4 (1.3–21.6)   Hypertension (N = 85)  1.0  0.7 (0.2–2.4)  3.2 (1.2–8.1)  5.2 (2.0–13.5)  23.2 (7.9–67.9)   Hyperlipidemia (N = 46)  1.0  —  4.0 (1.2–13.3)  5.4 (1.6–18.2)  10.5 (3.2–34.7)  Pulmonary   Asthma (N = 111)  1.0  2.6 (1.1–5.9)  2.8 (1.3–6.3)  1.4 (0.6–3.3)  1.5 (0.7–3.5)   Allergies (N = 104)  1.0  1.6 (0.7–3.6)  2.4 (1.1–5.2)  1.1 (0.5–2.5)  1.3 (0.5–2.9)  Endocrine/metabolic   Hypothyroid (N = 27)  1.0  1.5 (0.3–6.3)  1.5 (0.4–5.9)  2.8 (0.8–10.5)  3.1 (0.8–11.6)  Urinary/renal   Incontinence (N = 102)  1.0  1.1 (0.5–2.6)  1.2 (0.5–2.6)  0.9 (0.4–2.1)  1.8 (0.8–4.1)  Gastrointestinal   GERD (N = 97)  1.0  0.8 (0.3–1.7)  1.0 (0.5–2.2)  0.9 (0.4–2.1)  2.1 (0.9–4.7)  Musculoskeletal   Osteoporosis (N = 49)  1.0  2.7 (0.9–8.3)  0.9 (0.3–3.2)  2.4 (0.8–7.3)  7.9 (2.7–22.6)  General   Obesity (N = 97)  1.0  1.4 (0.6–3.2)  1.6 (0.7–3.5)  1.5 (0.7–3.6)  1.1 (0.5–2.7)  Outcome  18–29 years AORa (N = 56)  30–39 years AORa (N = 41)  40–49 years AORa (N = 51)  50–59 years AORa (N = 41)  ≥60 years AORa (N = 40)  Neurologic   Seizure disorder (N = 96)  1.0  1.6 (0.7–3.6)  0.8 (0.4–1.7)  0.8 (0.3–1.7)  0.5 (0.2–1.2)   Migraine/severe headache (N = 37)  1.0  2.0 (0.7–5.4)  1.2 (0.4–3.2)  0.9 (0.3–2.8)  0.3 (0.06–1.4)  Psychiatric   Depression (N = 54)  1.0  1.1 (0.4–3.3)  3.4 (1.3–8.6)  1.3 (0.5–3.8)  2.2 (0.8–6.2)   Anxiety disorder (N = 36)  1.0  2.3 (0.6–8.6)  4.1 (1.2–13.6)  3.2 (0.9–11.5)  2.4 (0.6–9.1)  Heart and circulatory   MI or stroke (N = 21)  1.0  0.4 (0.05–4.5)  2.0 (0.4–8.6)  1.4 (0.3–7.4)  5.4 (1.3–21.6)   Hypertension (N = 85)  1.0  0.7 (0.2–2.4)  3.2 (1.2–8.1)  5.2 (2.0–13.5)  23.2 (7.9–67.9)   Hyperlipidemia (N = 46)  1.0  —  4.0 (1.2–13.3)  5.4 (1.6–18.2)  10.5 (3.2–34.7)  Pulmonary   Asthma (N = 111)  1.0  2.6 (1.1–5.9)  2.8 (1.3–6.3)  1.4 (0.6–3.3)  1.5 (0.7–3.5)   Allergies (N = 104)  1.0  1.6 (0.7–3.6)  2.4 (1.1–5.2)  1.1 (0.5–2.5)  1.3 (0.5–2.9)  Endocrine/metabolic   Hypothyroid (N = 27)  1.0  1.5 (0.3–6.3)  1.5 (0.4–5.9)  2.8 (0.8–10.5)  3.1 (0.8–11.6)  Urinary/renal   Incontinence (N = 102)  1.0  1.1 (0.5–2.6)  1.2 (0.5–2.6)  0.9 (0.4–2.1)  1.8 (0.8–4.1)  Gastrointestinal   GERD (N = 97)  1.0  0.8 (0.3–1.7)  1.0 (0.5–2.2)  0.9 (0.4–2.1)  2.1 (0.9–4.7)  Musculoskeletal   Osteoporosis (N = 49)  1.0  2.7 (0.9–8.3)  0.9 (0.3–3.2)  2.4 (0.8–7.3)  7.9 (2.7–22.6)  General   Obesity (N = 97)  1.0  1.4 (0.6–3.2)  1.6 (0.7–3.5)  1.5 (0.7–3.6)  1.1 (0.5–2.7)  ADHD, attention deficit hyperactivity disorder; GERD, gastroesophageal disease. aAdjusted for gender. View Large Table 2. Health conditions across age groups in adults with CP from the RHSS-IV 2011–2014 Outcome  18–29 years AORa (N = 56)  30–39 years AORa (N = 41)  40–49 years AORa (N = 51)  50–59 years AORa (N = 41)  ≥60 years AORa (N = 40)  Neurologic   Seizure disorder (N = 96)  1.0  1.6 (0.7–3.6)  0.8 (0.4–1.7)  0.8 (0.3–1.7)  0.5 (0.2–1.2)   Migraine/severe headache (N = 37)  1.0  2.0 (0.7–5.4)  1.2 (0.4–3.2)  0.9 (0.3–2.8)  0.3 (0.06–1.4)  Psychiatric   Depression (N = 54)  1.0  1.1 (0.4–3.3)  3.4 (1.3–8.6)  1.3 (0.5–3.8)  2.2 (0.8–6.2)   Anxiety disorder (N = 36)  1.0  2.3 (0.6–8.6)  4.1 (1.2–13.6)  3.2 (0.9–11.5)  2.4 (0.6–9.1)  Heart and circulatory   MI or stroke (N = 21)  1.0  0.4 (0.05–4.5)  2.0 (0.4–8.6)  1.4 (0.3–7.4)  5.4 (1.3–21.6)   Hypertension (N = 85)  1.0  0.7 (0.2–2.4)  3.2 (1.2–8.1)  5.2 (2.0–13.5)  23.2 (7.9–67.9)   Hyperlipidemia (N = 46)  1.0  —  4.0 (1.2–13.3)  5.4 (1.6–18.2)  10.5 (3.2–34.7)  Pulmonary   Asthma (N = 111)  1.0  2.6 (1.1–5.9)  2.8 (1.3–6.3)  1.4 (0.6–3.3)  1.5 (0.7–3.5)   Allergies (N = 104)  1.0  1.6 (0.7–3.6)  2.4 (1.1–5.2)  1.1 (0.5–2.5)  1.3 (0.5–2.9)  Endocrine/metabolic   Hypothyroid (N = 27)  1.0  1.5 (0.3–6.3)  1.5 (0.4–5.9)  2.8 (0.8–10.5)  3.1 (0.8–11.6)  Urinary/renal   Incontinence (N = 102)  1.0  1.1 (0.5–2.6)  1.2 (0.5–2.6)  0.9 (0.4–2.1)  1.8 (0.8–4.1)  Gastrointestinal   GERD (N = 97)  1.0  0.8 (0.3–1.7)  1.0 (0.5–2.2)  0.9 (0.4–2.1)  2.1 (0.9–4.7)  Musculoskeletal   Osteoporosis (N = 49)  1.0  2.7 (0.9–8.3)  0.9 (0.3–3.2)  2.4 (0.8–7.3)  7.9 (2.7–22.6)  General   Obesity (N = 97)  1.0  1.4 (0.6–3.2)  1.6 (0.7–3.5)  1.5 (0.7–3.6)  1.1 (0.5–2.7)  Outcome  18–29 years AORa (N = 56)  30–39 years AORa (N = 41)  40–49 years AORa (N = 51)  50–59 years AORa (N = 41)  ≥60 years AORa (N = 40)  Neurologic   Seizure disorder (N = 96)  1.0  1.6 (0.7–3.6)  0.8 (0.4–1.7)  0.8 (0.3–1.7)  0.5 (0.2–1.2)   Migraine/severe headache (N = 37)  1.0  2.0 (0.7–5.4)  1.2 (0.4–3.2)  0.9 (0.3–2.8)  0.3 (0.06–1.4)  Psychiatric   Depression (N = 54)  1.0  1.1 (0.4–3.3)  3.4 (1.3–8.6)  1.3 (0.5–3.8)  2.2 (0.8–6.2)   Anxiety disorder (N = 36)  1.0  2.3 (0.6–8.6)  4.1 (1.2–13.6)  3.2 (0.9–11.5)  2.4 (0.6–9.1)  Heart and circulatory   MI or stroke (N = 21)  1.0  0.4 (0.05–4.5)  2.0 (0.4–8.6)  1.4 (0.3–7.4)  5.4 (1.3–21.6)   Hypertension (N = 85)  1.0  0.7 (0.2–2.4)  3.2 (1.2–8.1)  5.2 (2.0–13.5)  23.2 (7.9–67.9)   Hyperlipidemia (N = 46)  1.0  —  4.0 (1.2–13.3)  5.4 (1.6–18.2)  10.5 (3.2–34.7)  Pulmonary   Asthma (N = 111)  1.0  2.6 (1.1–5.9)  2.8 (1.3–6.3)  1.4 (0.6–3.3)  1.5 (0.7–3.5)   Allergies (N = 104)  1.0  1.6 (0.7–3.6)  2.4 (1.1–5.2)  1.1 (0.5–2.5)  1.3 (0.5–2.9)  Endocrine/metabolic   Hypothyroid (N = 27)  1.0  1.5 (0.3–6.3)  1.5 (0.4–5.9)  2.8 (0.8–10.5)  3.1 (0.8–11.6)  Urinary/renal   Incontinence (N = 102)  1.0  1.1 (0.5–2.6)  1.2 (0.5–2.6)  0.9 (0.4–2.1)  1.8 (0.8–4.1)  Gastrointestinal   GERD (N = 97)  1.0  0.8 (0.3–1.7)  1.0 (0.5–2.2)  0.9 (0.4–2.1)  2.1 (0.9–4.7)  Musculoskeletal   Osteoporosis (N = 49)  1.0  2.7 (0.9–8.3)  0.9 (0.3–3.2)  2.4 (0.8–7.3)  7.9 (2.7–22.6)  General   Obesity (N = 97)  1.0  1.4 (0.6–3.2)  1.6 (0.7–3.5)  1.5 (0.7–3.6)  1.1 (0.5–2.7)  ADHD, attention deficit hyperactivity disorder; GERD, gastroesophageal disease. aAdjusted for gender. View Large Fewer than half of the participants were independent with all of the activities of daily living (ADL) (Table 3). The percent of those reporting independence with all ADLs decreased from 35.7% in those aged 18–29 years of age to 22.5% in those 59 and over. Adjusting for age, gender and intellectual status, several comorbidities were associated with lower overall functional self-care or walking status, including seizure disorder, urinary incontinence and gastroesophageal reflux disease (GERD) (Table 4). Hypertension, hyperlipidemia, hypothyroidism, myocardial infraction/stroke and diabetes were not associated with functional status or walking status. Table 3. Functional status and independence with ADLs in adults with CP from the RHSS-IV 2011–2014 Activity  18–29 years N = 56 (%)  30–39 years N = 41 (%)  40–49 years N = 51 (%)  50–59 years N = 41 (%)  ≥60 years N = 40 (%)  Walking status   Independent/mostly independent  48.2  58.5  62.8  63.4  40.0   Nonambulatory/some ambulation with assistance  51.8  41.5  37.3  36.6  60.0  Independent with all ADLs  35.7  41.5  31.4  36.6  22.5  Eating   Independent  39.3  41.5  35.3  36.5  25.0   Supervision or verbal prompt  21.4  43.9  54.9  48.8  62.5   Requires assistance or totally dependent  39.3  14.6  9.8  14.6  12.5  Dressing   Independent  37.5  41.5  33.3  36.6  22.5   Supervision or verbal prompt  23.2  39.0  54.9  43.9  50.0   Requires assistance or totally dependent  39.3  19.5  11.8  19.5  27.5  Bathing and washing   Independent  39.3  41.5  33.3  37.5  22.5   Supervision or verbal prompt  7.1  19.5  27.5  30.0  20.0   Requires assistance or totally dependent  53.6  39.0  39.2  32.5  57.5  Toileting   Independent  39.3  41.5  35.3  39.0  25.0   Supervision or verbal prompt  19.6  39.0  52.9  41.5  47.5   Requires assistance or totally dependent  41.1  19.5  11.8  19.5  27.5  Activity  18–29 years N = 56 (%)  30–39 years N = 41 (%)  40–49 years N = 51 (%)  50–59 years N = 41 (%)  ≥60 years N = 40 (%)  Walking status   Independent/mostly independent  48.2  58.5  62.8  63.4  40.0   Nonambulatory/some ambulation with assistance  51.8  41.5  37.3  36.6  60.0  Independent with all ADLs  35.7  41.5  31.4  36.6  22.5  Eating   Independent  39.3  41.5  35.3  36.5  25.0   Supervision or verbal prompt  21.4  43.9  54.9  48.8  62.5   Requires assistance or totally dependent  39.3  14.6  9.8  14.6  12.5  Dressing   Independent  37.5  41.5  33.3  36.6  22.5   Supervision or verbal prompt  23.2  39.0  54.9  43.9  50.0   Requires assistance or totally dependent  39.3  19.5  11.8  19.5  27.5  Bathing and washing   Independent  39.3  41.5  33.3  37.5  22.5   Supervision or verbal prompt  7.1  19.5  27.5  30.0  20.0   Requires assistance or totally dependent  53.6  39.0  39.2  32.5  57.5  Toileting   Independent  39.3  41.5  35.3  39.0  25.0   Supervision or verbal prompt  19.6  39.0  52.9  41.5  47.5   Requires assistance or totally dependent  41.1  19.5  11.8  19.5  27.5  View Large Table 3. Functional status and independence with ADLs in adults with CP from the RHSS-IV 2011–2014 Activity  18–29 years N = 56 (%)  30–39 years N = 41 (%)  40–49 years N = 51 (%)  50–59 years N = 41 (%)  ≥60 years N = 40 (%)  Walking status   Independent/mostly independent  48.2  58.5  62.8  63.4  40.0   Nonambulatory/some ambulation with assistance  51.8  41.5  37.3  36.6  60.0  Independent with all ADLs  35.7  41.5  31.4  36.6  22.5  Eating   Independent  39.3  41.5  35.3  36.5  25.0   Supervision or verbal prompt  21.4  43.9  54.9  48.8  62.5   Requires assistance or totally dependent  39.3  14.6  9.8  14.6  12.5  Dressing   Independent  37.5  41.5  33.3  36.6  22.5   Supervision or verbal prompt  23.2  39.0  54.9  43.9  50.0   Requires assistance or totally dependent  39.3  19.5  11.8  19.5  27.5  Bathing and washing   Independent  39.3  41.5  33.3  37.5  22.5   Supervision or verbal prompt  7.1  19.5  27.5  30.0  20.0   Requires assistance or totally dependent  53.6  39.0  39.2  32.5  57.5  Toileting   Independent  39.3  41.5  35.3  39.0  25.0   Supervision or verbal prompt  19.6  39.0  52.9  41.5  47.5   Requires assistance or totally dependent  41.1  19.5  11.8  19.5  27.5  Activity  18–29 years N = 56 (%)  30–39 years N = 41 (%)  40–49 years N = 51 (%)  50–59 years N = 41 (%)  ≥60 years N = 40 (%)  Walking status   Independent/mostly independent  48.2  58.5  62.8  63.4  40.0   Nonambulatory/some ambulation with assistance  51.8  41.5  37.3  36.6  60.0  Independent with all ADLs  35.7  41.5  31.4  36.6  22.5  Eating   Independent  39.3  41.5  35.3  36.5  25.0   Supervision or verbal prompt  21.4  43.9  54.9  48.8  62.5   Requires assistance or totally dependent  39.3  14.6  9.8  14.6  12.5  Dressing   Independent  37.5  41.5  33.3  36.6  22.5   Supervision or verbal prompt  23.2  39.0  54.9  43.9  50.0   Requires assistance or totally dependent  39.3  19.5  11.8  19.5  27.5  Bathing and washing   Independent  39.3  41.5  33.3  37.5  22.5   Supervision or verbal prompt  7.1  19.5  27.5  30.0  20.0   Requires assistance or totally dependent  53.6  39.0  39.2  32.5  57.5  Toileting   Independent  39.3  41.5  35.3  39.0  25.0   Supervision or verbal prompt  19.6  39.0  52.9  41.5  47.5   Requires assistance or totally dependent  41.1  19.5  11.8  19.5  27.5  View Large Table 4. Adults with cerebral palsy independent with activities of daily living and independent or mostly independent with walking from the RHSS-IV 2011–2014 Factor  ADL  Walking  Independent ADLsa (%)  P†  AORb (95% CI)  Independent/mostly walking* (%)  P†  AORc (95% CI)  Age    0.19d      0.81d     18–29 (N = 56)  35.7    1.0  48.2    1.0   30–39 (N = 41)  41.5    1.8 (0.7–5.1)  58.5    1.7 (0.7–3.9)   40–49 (N = 51)  31.4    0.7 (0.3–1.9)  62.8    1.8 (0.8–4.1)   50–59 (N = 41)  36.6    0.6 (0.2–1.8)  63.4    1.6 (0.7–3.8)   ≥60 (N = 40)  22.5    0.3 (0.1–1.8)  40.0    0.6 (0.2–1.4)  Gender    0.69      0.93     Male (N = 135)  32.6    1.0  54.8    1.0   Female (N = 94)  35.1    1.0 (0.5–1.8)  54.3    0.9 (0.5–1.6)  Intellectually disabled    <0.001      0.09     No (N = 105)  59.1    1.0  85.7    1.0   Yes (N = 124)  12.1    0.1 (0.03–0.1)  53.6    0.3 (0.2–0.6)  Health conditions               Seizure disorder    <0.001      <0.001      No (N = 133)  43.6    1.0  63.9    1.0    Yes (N = 96)  19.8    0.4 (0.2–0.8)  41.7    0.4 (0.2–0.8)   Urinary incontinence    <0.001      <0.001      No (N = 127)  55.9    1.0  77.2    1.0    Yes (N = 102)  5.9    0.1 (0.02–0.2)  26.5    0.1 (0.1–0.2)   GERD    0.007      <0.001      No (N = 132)  40.9    1.0  66.7    1.0    Yes (N = 97)  23.7    0.4 (0.2–0.8)  38.1    0.3 (0.2–0.5)   Anxiety    0.02      0.01      No (N = 193)  30.6    1.0  50.8    1.0    Yes (N = 36)  50.0    2.8 (1.2–7.0)  75.0    2.6 (1.1–6.1)   Depression    0.05      0.43      No (N = 175)  30.3    1.0  53.1    1.0    Yes (N = 54)  44.4    1.2 (0.6–2.6)  59.3    —   Migraines    <0.001      0.01      No (N = 192)  28.7    1.0  51.0    1.0    Yes (N = 37)  59.5    1.8 (0.8–4.2)  73.0    1.8 (0.8–4.1)  Factor  ADL  Walking  Independent ADLsa (%)  P†  AORb (95% CI)  Independent/mostly walking* (%)  P†  AORc (95% CI)  Age    0.19d      0.81d     18–29 (N = 56)  35.7    1.0  48.2    1.0   30–39 (N = 41)  41.5    1.8 (0.7–5.1)  58.5    1.7 (0.7–3.9)   40–49 (N = 51)  31.4    0.7 (0.3–1.9)  62.8    1.8 (0.8–4.1)   50–59 (N = 41)  36.6    0.6 (0.2–1.8)  63.4    1.6 (0.7–3.8)   ≥60 (N = 40)  22.5    0.3 (0.1–1.8)  40.0    0.6 (0.2–1.4)  Gender    0.69      0.93     Male (N = 135)  32.6    1.0  54.8    1.0   Female (N = 94)  35.1    1.0 (0.5–1.8)  54.3    0.9 (0.5–1.6)  Intellectually disabled    <0.001      0.09     No (N = 105)  59.1    1.0  85.7    1.0   Yes (N = 124)  12.1    0.1 (0.03–0.1)  53.6    0.3 (0.2–0.6)  Health conditions               Seizure disorder    <0.001      <0.001      No (N = 133)  43.6    1.0  63.9    1.0    Yes (N = 96)  19.8    0.4 (0.2–0.8)  41.7    0.4 (0.2–0.8)   Urinary incontinence    <0.001      <0.001      No (N = 127)  55.9    1.0  77.2    1.0    Yes (N = 102)  5.9    0.1 (0.02–0.2)  26.5    0.1 (0.1–0.2)   GERD    0.007      <0.001      No (N = 132)  40.9    1.0  66.7    1.0    Yes (N = 97)  23.7    0.4 (0.2–0.8)  38.1    0.3 (0.2–0.5)   Anxiety    0.02      0.01      No (N = 193)  30.6    1.0  50.8    1.0    Yes (N = 36)  50.0    2.8 (1.2–7.0)  75.0    2.6 (1.1–6.1)   Depression    0.05      0.43      No (N = 175)  30.3    1.0  53.1    1.0    Yes (N = 54)  44.4    1.2 (0.6–2.6)  59.3    —   Migraines    <0.001      0.01      No (N = 192)  28.7    1.0  51.0    1.0    Yes (N = 37)  59.5    1.8 (0.8–4.2)  73.0    1.8 (0.8–4.1)  aPercent of adults who are independent with all ADLs (eating, dressing, bathing and toileting). bLogistic model includes age, gender, ID level and individually with health conditions that have a P < 0.2 on bivariate comparison (GERD, seizure disorder, migraines, anxiety, depression and urinary incontinence). cLogistic model includes age, gender, ID level, and individually with health conditions that have a P < 0.2 on bivariate comparison (GERD, seizure disorder, migraines, anxiety and urinary incontinence). dCochran–Armitage trend test. †Chi-square test unless otherwise specified. View Large Table 4. Adults with cerebral palsy independent with activities of daily living and independent or mostly independent with walking from the RHSS-IV 2011–2014 Factor  ADL  Walking  Independent ADLsa (%)  P†  AORb (95% CI)  Independent/mostly walking* (%)  P†  AORc (95% CI)  Age    0.19d      0.81d     18–29 (N = 56)  35.7    1.0  48.2    1.0   30–39 (N = 41)  41.5    1.8 (0.7–5.1)  58.5    1.7 (0.7–3.9)   40–49 (N = 51)  31.4    0.7 (0.3–1.9)  62.8    1.8 (0.8–4.1)   50–59 (N = 41)  36.6    0.6 (0.2–1.8)  63.4    1.6 (0.7–3.8)   ≥60 (N = 40)  22.5    0.3 (0.1–1.8)  40.0    0.6 (0.2–1.4)  Gender    0.69      0.93     Male (N = 135)  32.6    1.0  54.8    1.0   Female (N = 94)  35.1    1.0 (0.5–1.8)  54.3    0.9 (0.5–1.6)  Intellectually disabled    <0.001      0.09     No (N = 105)  59.1    1.0  85.7    1.0   Yes (N = 124)  12.1    0.1 (0.03–0.1)  53.6    0.3 (0.2–0.6)  Health conditions               Seizure disorder    <0.001      <0.001      No (N = 133)  43.6    1.0  63.9    1.0    Yes (N = 96)  19.8    0.4 (0.2–0.8)  41.7    0.4 (0.2–0.8)   Urinary incontinence    <0.001      <0.001      No (N = 127)  55.9    1.0  77.2    1.0    Yes (N = 102)  5.9    0.1 (0.02–0.2)  26.5    0.1 (0.1–0.2)   GERD    0.007      <0.001      No (N = 132)  40.9    1.0  66.7    1.0    Yes (N = 97)  23.7    0.4 (0.2–0.8)  38.1    0.3 (0.2–0.5)   Anxiety    0.02      0.01      No (N = 193)  30.6    1.0  50.8    1.0    Yes (N = 36)  50.0    2.8 (1.2–7.0)  75.0    2.6 (1.1–6.1)   Depression    0.05      0.43      No (N = 175)  30.3    1.0  53.1    1.0    Yes (N = 54)  44.4    1.2 (0.6–2.6)  59.3    —   Migraines    <0.001      0.01      No (N = 192)  28.7    1.0  51.0    1.0    Yes (N = 37)  59.5    1.8 (0.8–4.2)  73.0    1.8 (0.8–4.1)  Factor  ADL  Walking  Independent ADLsa (%)  P†  AORb (95% CI)  Independent/mostly walking* (%)  P†  AORc (95% CI)  Age    0.19d      0.81d     18–29 (N = 56)  35.7    1.0  48.2    1.0   30–39 (N = 41)  41.5    1.8 (0.7–5.1)  58.5    1.7 (0.7–3.9)   40–49 (N = 51)  31.4    0.7 (0.3–1.9)  62.8    1.8 (0.8–4.1)   50–59 (N = 41)  36.6    0.6 (0.2–1.8)  63.4    1.6 (0.7–3.8)   ≥60 (N = 40)  22.5    0.3 (0.1–1.8)  40.0    0.6 (0.2–1.4)  Gender    0.69      0.93     Male (N = 135)  32.6    1.0  54.8    1.0   Female (N = 94)  35.1    1.0 (0.5–1.8)  54.3    0.9 (0.5–1.6)  Intellectually disabled    <0.001      0.09     No (N = 105)  59.1    1.0  85.7    1.0   Yes (N = 124)  12.1    0.1 (0.03–0.1)  53.6    0.3 (0.2–0.6)  Health conditions               Seizure disorder    <0.001      <0.001      No (N = 133)  43.6    1.0  63.9    1.0    Yes (N = 96)  19.8    0.4 (0.2–0.8)  41.7    0.4 (0.2–0.8)   Urinary incontinence    <0.001      <0.001      No (N = 127)  55.9    1.0  77.2    1.0    Yes (N = 102)  5.9    0.1 (0.02–0.2)  26.5    0.1 (0.1–0.2)   GERD    0.007      <0.001      No (N = 132)  40.9    1.0  66.7    1.0    Yes (N = 97)  23.7    0.4 (0.2–0.8)  38.1    0.3 (0.2–0.5)   Anxiety    0.02      0.01      No (N = 193)  30.6    1.0  50.8    1.0    Yes (N = 36)  50.0    2.8 (1.2–7.0)  75.0    2.6 (1.1–6.1)   Depression    0.05      0.43      No (N = 175)  30.3    1.0  53.1    1.0    Yes (N = 54)  44.4    1.2 (0.6–2.6)  59.3    —   Migraines    <0.001      0.01      No (N = 192)  28.7    1.0  51.0    1.0    Yes (N = 37)  59.5    1.8 (0.8–4.2)  73.0    1.8 (0.8–4.1)  aPercent of adults who are independent with all ADLs (eating, dressing, bathing and toileting). bLogistic model includes age, gender, ID level and individually with health conditions that have a P < 0.2 on bivariate comparison (GERD, seizure disorder, migraines, anxiety, depression and urinary incontinence). cLogistic model includes age, gender, ID level, and individually with health conditions that have a P < 0.2 on bivariate comparison (GERD, seizure disorder, migraines, anxiety and urinary incontinence). dCochran–Armitage trend test. †Chi-square test unless otherwise specified. View Large Table 5 demonstrates health care utilization stratified by age. All age groups reported greater use of primary care services compared to use of the ED. Both primary care and ED utilization increased with advancing age group. In adults aged 60 and over, 42.5% reported seeing a neurologist, 47.5% reported visiting a physical therapist, 20.0% reported visiting an occupational therapist and 20.0% reported seeing a psychiatrist in the last 24 months. Table 5. Health care utilization by individuals with CP by age groups from the RRHS-IV 2011–2014 Utilization in the last 24 months  18–29 years N = 56 (%)  30–39 years N = 41 (%)  40–49 years N = 51 (%)  50–59 years N = 41 (%)  ≥60 years N = 40 (%)  Number of primary care visits   None  26.8  22.0  7.8  12.2  7.5   1 or 2  23.3  39.0  43.1  34.2  30.0   3 or more  50.0  39.0  49.0  53.7  62.5  Number of ED visits   None  64.3  51.2  68.6  70.7  50.0   1 or 2  23.2  41.5  25.5  22.0  35.0   3 or more  12.5  7.3  5.9  7.3  15.0  Number of specialty care visits   None  14.3  17.1  15.7  14.6  2.5   Psychiatrist  16.1  17.1  21.6  24.4  20.0   Psychologist  3.6  4.9  0.0  4.9  0.0   Neurologist  37.5  48.8  27.5  31.7  42.5   Orthopaedic  17.9  22.0  21.6  17.1  30.0   Physical therapist  48.2  34.2  31.4  34.2  47.5   Occupational therapist  28.6  17.1  17.7  14.6  20.0   Speech pathologist  14.3  9.8  9.8  0.0  5.0   Podiatrist  7.1  9.8  7.8  14.6  22.5   Other  48.2  22.0  39.2  22.2  52.5  Utilization in the last 24 months  18–29 years N = 56 (%)  30–39 years N = 41 (%)  40–49 years N = 51 (%)  50–59 years N = 41 (%)  ≥60 years N = 40 (%)  Number of primary care visits   None  26.8  22.0  7.8  12.2  7.5   1 or 2  23.3  39.0  43.1  34.2  30.0   3 or more  50.0  39.0  49.0  53.7  62.5  Number of ED visits   None  64.3  51.2  68.6  70.7  50.0   1 or 2  23.2  41.5  25.5  22.0  35.0   3 or more  12.5  7.3  5.9  7.3  15.0  Number of specialty care visits   None  14.3  17.1  15.7  14.6  2.5   Psychiatrist  16.1  17.1  21.6  24.4  20.0   Psychologist  3.6  4.9  0.0  4.9  0.0   Neurologist  37.5  48.8  27.5  31.7  42.5   Orthopaedic  17.9  22.0  21.6  17.1  30.0   Physical therapist  48.2  34.2  31.4  34.2  47.5   Occupational therapist  28.6  17.1  17.7  14.6  20.0   Speech pathologist  14.3  9.8  9.8  0.0  5.0   Podiatrist  7.1  9.8  7.8  14.6  22.5   Other  48.2  22.0  39.2  22.2  52.5  View Large Table 5. Health care utilization by individuals with CP by age groups from the RRHS-IV 2011–2014 Utilization in the last 24 months  18–29 years N = 56 (%)  30–39 years N = 41 (%)  40–49 years N = 51 (%)  50–59 years N = 41 (%)  ≥60 years N = 40 (%)  Number of primary care visits   None  26.8  22.0  7.8  12.2  7.5   1 or 2  23.3  39.0  43.1  34.2  30.0   3 or more  50.0  39.0  49.0  53.7  62.5  Number of ED visits   None  64.3  51.2  68.6  70.7  50.0   1 or 2  23.2  41.5  25.5  22.0  35.0   3 or more  12.5  7.3  5.9  7.3  15.0  Number of specialty care visits   None  14.3  17.1  15.7  14.6  2.5   Psychiatrist  16.1  17.1  21.6  24.4  20.0   Psychologist  3.6  4.9  0.0  4.9  0.0   Neurologist  37.5  48.8  27.5  31.7  42.5   Orthopaedic  17.9  22.0  21.6  17.1  30.0   Physical therapist  48.2  34.2  31.4  34.2  47.5   Occupational therapist  28.6  17.1  17.7  14.6  20.0   Speech pathologist  14.3  9.8  9.8  0.0  5.0   Podiatrist  7.1  9.8  7.8  14.6  22.5   Other  48.2  22.0  39.2  22.2  52.5  Utilization in the last 24 months  18–29 years N = 56 (%)  30–39 years N = 41 (%)  40–49 years N = 51 (%)  50–59 years N = 41 (%)  ≥60 years N = 40 (%)  Number of primary care visits   None  26.8  22.0  7.8  12.2  7.5   1 or 2  23.3  39.0  43.1  34.2  30.0   3 or more  50.0  39.0  49.0  53.7  62.5  Number of ED visits   None  64.3  51.2  68.6  70.7  50.0   1 or 2  23.2  41.5  25.5  22.0  35.0   3 or more  12.5  7.3  5.9  7.3  15.0  Number of specialty care visits   None  14.3  17.1  15.7  14.6  2.5   Psychiatrist  16.1  17.1  21.6  24.4  20.0   Psychologist  3.6  4.9  0.0  4.9  0.0   Neurologist  37.5  48.8  27.5  31.7  42.5   Orthopaedic  17.9  22.0  21.6  17.1  30.0   Physical therapist  48.2  34.2  31.4  34.2  47.5   Occupational therapist  28.6  17.1  17.7  14.6  20.0   Speech pathologist  14.3  9.8  9.8  0.0  5.0   Podiatrist  7.1  9.8  7.8  14.6  22.5   Other  48.2  22.0  39.2  22.2  52.5  View Large Discussion Most adults with CP are living into older adulthood and receive a substantial amount of their care from PCPs, highlighting the importance of physicians to be skilled at providing care to adults with CP. This cross-sectional study of 229 adults with CP identified high rates of seizure disorder, hypertension, depression and anxiety. We also identified multiple health conditions common in the general population and associated changes in functional status. Therefore, comprehensive care of adults with CP must address health conditions specifically associated with CP, conditions common with aging and evolving changes in functional status. Mortality records reveal that death due to heart disease is higher among adults with CP compared to the general population (34). We found that hypertension, hyperlipidemia, myocardial infarction and stroke all increased in prevalence across the advancing age groups of adults with CP. We also found high rates of hypertension in adults with CP. Our results support prior findings of high rates of obesity and metabolic syndrome in adults with CP (10,11,13,16), emphasizing the potential association of cardiac risk factors and CP. Although the predominance of evidence support these associations, it is important to acknowledge that measurement inaccuracies in blood pressure related to spasticity are commonly seen in CP. In total, the increased rates of hypertension, metabolic syndrome and cardiovascular risk factors all point to the silent threat that hypertension poses to adults with CP (13,16). This association between hypertension, cardiovascular disease and CP requires further evaluation to better elucidate potential physiologic mechanisms, and possible areas of early recognition and intervention. We also identified a high prevalence of anxiety and depression in adults with CP. Mood disorders have been well described among people with intellectual and developmental disabilities, but depression and anxiety are less well documented in adults with CP (35–37). A study from the Netherlands similarly found an increased prevalence of depressive symptoms in adults with CP compared to the Dutch population (15). It is important for PCPs to recognize any underlying mood disorders. It is interesting to note that, even in the oldest age groups, only around 20% had seen a psychiatrist in the past 24 months. This further reinforces the need to address any evolving mental health conditions within primary care. Depression is a potentially treatable conditions and treatment may offer an opportunity to improve health and physical functioning in adults with CP. In our study, adults with CP had significantly increased rates of seizure disorders compared to the general population across all age groups, similar to prior studies (38). The higher prevalence of seizures disorders is particularly important to recognize, manage and monitor given its association with increased mortality, increased inpatient admissions and decreased functional status (39,40). Respiratory illnesses are also a leading cause of hospitalization and a significant contributor to excess mortality in CP (10,34,41). Consistent with a prior study, we found higher rates of asthma in adults with CP across all age groups (11). It is possible that recurrent aspiration events may contribute to increased bronchospasm. It is therefore important for PCPs to recognize asthma and possible aspiration events. Adults with CP were also found to have several health conditions that are commonly seen in the general population with aging, including osteoporosis, hyperlipidemia and hypothyroidism. Commonly occurring conditions frequently go undetected in persons with developmental disabilities due to barriers to accessing health care, receiving treatments and with communication regarding health conditions (42–48). Clinical recognition of these conditions and open communication is critical to improving general health and providing comprehensive care to adults with CP. In contrast to other conditions, we found a decreased prevalence of tobacco dependence and alcohol misuse in adults with CP. This may be a result of providers being less likely to inquire about substance use in this population (49). It is also possible that exposures to these substances are limited either due to the condition itself or social consequences of the condition. Similarly, we found that young adults aged 18–29 with CP had lower rates of STIs compared to the general population. These rates increased, however, in adults with CP aged 30–59 to rates similar to the general population. While the reasons are not clear, it is possible that sexual activity may be delayed in adults with CP compared to the general population. It remains important for PCPs to query their adult patients with CP about sexual practices and symptoms of STIs. Functional self-care and ambulation in adults with CP was found to decrease with advancing age and the majority of the sample required at least some assistance with basic ADLs at all ages. We further found functional status was adversely associated with only a few health conditions, suggesting that level of functional independence may be generally independent of many health conditions. The presence of a seizure disorder or urinary incontinence was associated with lower independence in ADLs and mobility, likely related to the direct limitations imparted by these conditions. The presence of an intellectual disability was also associated with lower independence in ADLs and mobility, likely reflecting greater overall impairments. Assessing and working to optimize functional status is an important component of care that is shared across multiple specialties. We found that visits to physical therapists were common across all age groups, but visits to occupational therapists and speech pathologists were substantially less frequent. Ensuring adequate access to physical therapists, occupational therapists and physical medicine and rehabilitation providers is an important component of the comprehensive care necessary to optimize functional status. Access to primary care is also essential to address health conditions and functional status. In our study population, primary care utilization remained greater than ED use across all age groups. Prior literature has demonstrated that adults with physically disabling conditions from childhood require frequent services, are less likely to receive preventive care, and frequently have unmet health care needs (21–23,50). Coordination of care with an interdisciplinary approach is essential to ensure appropriate ambulatory care, address unmet health care needs and reduce unnecessary ED utilization (20,22,23,51). This cross-sectional study has several limitations. Although the generalizability of these findings is supported by the broad source of data across 35 practices and 5 counties, the fact that the network is part of a single academic institution warrants caution. It is possible that selection bias from a regional and academic network may have influenced the results and overall generalizability. This may have resulted in a cohort with higher medical acuity and more complex needs, or may have missed conditions with lower prevalence (52). Our sample was mainly male, consistent with the gender differences seen in CP (4,53). Health information may also have been missed if it was underreported in chart reviews. Health status, functional status and intellectual capacity were determined by an in-depth review of notes and documentation from the PCP, physical/occupational therapists, sub-specialists and mental health therapists, but underreporting may still occur. Unfortunately, we do not have specific information about the GMFCS level, the topographic type of CP or specific IQ level. Conclusions Within our cohort, adults with CP had an increased prevalence of seizures disorders, hypertension, asthma, depression and obesity compared to the general population. Several of these conditions are associated with increased mortality and loss of functional status, and thus it is imperative to recognize and treat them accordingly. Adults with CP also develop many health conditions commonly seen in the general population with advancing age. Health conditions frequently go undetected in persons with developmental disabilities. Therefore, clinicians must ensure that adults with CP are screened and treated not just for conditions associated with CP, but also conditions that are common with aging in general. Declaration Funding: This research was supported in part by a sub-contract to the University of Rochester from the Rehabilitation Research and Training Center on Aging with Developmental Disabilities (RRTCADD), Department of Disability and Human Development at the University of Illinois at Chicago. The RRTCADD is funded by Grant # H133B080009 from the US Department of Education, Office of Special Education and Rehabilitative Services, National Institute on Disability and Rehabilitation Research. Ethical approval: This study was approved by the University of Rochester Research Subjects Review Board and the protocols used by NHANES and NHIS were approved by the National Center for Health Statistics (NCHS) Institutional Review Board. Conflict of Interest: none. References 1. Rosenbaum P, Paneth N, Leviton A, et al.   A report: the definition and classification of cerebral palsy April 2006. Dev Med Child Neurol Suppl  2007; 109( Suppl 109): 8– 14. Google Scholar PubMed  2. Turk MA. 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Google Scholar CrossRef Search ADS PubMed  52. Robertson J, Hatton C, Emerson E, Baines S. The impact of health checks for people with intellectual disabilities: an updated systematic review of evidence. Res Dev Disabil  2014; 35: 2450– 62. Google Scholar CrossRef Search ADS PubMed  53. Chounti A, Hägglund G, Wagner P, Westbom L. Sex differences in cerebral palsy incidence and functional ability: a total population study. Acta Paediatr  2013; 102: 712– 7. Google Scholar CrossRef Search ADS PubMed  © The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Family Practice Oxford University Press

Health conditions, functional status and health care utilization in adults with cerebral palsy

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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
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0263-2136
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1460-2229
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10.1093/fampra/cmy027
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Abstract

Abstract Aim Health conditions in children with cerebral palsy (CP) are well described, yet health is less defined with advancing age. We examined health conditions, functional status and health care utilization in adults with CP across age groups. Methods We collected cross-sectional data on health conditions, functional status and utilization from the medical records of adults with CP across a large university-affiliated primary care network using the Rochester Health Status Survey IV (RHSS-IV), a 58-item validated survey. Data from the National Health and Nutrition Examination Survey and National Health Interview Survey provided prevalence estimates for the general population as comparison. Results Compared to the general population, adults with CP had higher rates of seizure disorder, obesity and asthma across all ages. Adults with CP under 30 years of age had higher rates of hypertension (16.7 versus 5.6%; P = 0.04), urinary incontinence (41.7 versus 10.5%; P < 0.001) and depression (16.7 versus 6.9%; P = 0.07). Conversely, there were lower rates of alcohol misuse, tobacco/nicotine and sexually transmitted illnesses. Independence with all activities of daily living decreased from 37.5% at 18–29 years of age to 22.5% in those 60 and over. Seizure disorders, urinary incontinence and gastroesophageal reflux disease were all independently associated with lower functional status. As expected, health care utilization increased with advancing age. Conclusions Adults with CP should be monitored for conditions occurring at higher prevalence in CP, as well as common conditions occurring with advancing age. Age-related functional decline should be anticipated, especially with coexisting seizure disorders and urinary incontinence. Access to care, aging, chronic disease, developmental disabilities, motor development, cerebral palsy Introduction Cerebral palsy (CP) is a neurodevelopmental condition characterized by abnormal muscle tone, spasticity and altered posture. CP is caused by a heterogeneous range of abnormalities in the developing brain and affects between 1.5 and 4 patients per 1000 births (1–5). Advances in medical care have resulted in increasing life expectancy of people with CP, with many living into later adulthood (6,7). Many of these adults are living in community settings and, in turn, receive their health care in traditional primary care settings. Therefore, it is important that primary care physicians (PCPs) are equipped to care for adults with CP, including recognizing comorbid medical conditions associated with aging. Although health conditions in children with CP are well described, health conditions, functional status and health care utilization remain less defined with advancing age (8). The most commonly reported health conditions in adults with CP involve increasing musculoskeletal impairments, fatigue, pain, seizures, intellectual disabilities and osteoporosis (2,9–16). Functional decline and associations among chronic disease in adults with CP has been described (10,17,18), but the influence of medical conditions on functional status has not been explored (19). It is also important to understand how adults with CP access health care. Prior evidence has suggested that individuals with developmental disabilities receive less preventive care and utilize the emergency department (ED) at higher rates due to barriers to care (20–23), but little evidence exists around utilization patterns specific to adults with CP. To advance our clinical understanding of adults with CP, this study aimed to (i) examine the health conditions and functional status in adults with CP across age groups; (ii) identify factors associated with walking and activities of daily living; and (iii) explore health care utilization by adults with CP. Methods CP subject identification and age groups Adults with CP were identified throughout a large university-affiliated primary care network of 35 practices across 5 counties in Western upstate New York. Adults with CP were identified based on a query of the electronic health record using the International Classification of Diseases, Ninth Revision (ICD-9) codes of 343.xx on the problem list (24). The diagnosis of CP was established through direct chart review prior to manual data abstraction. The sample was divided into five age groups to investigate health status associated with age, consistent with similar literature (25,26). The five age groups were comprised of participants aged 18–29, 30–39, 40–49, 50–59 and >59 years. Rochester health status survey (RHSS) Cross-sectional data were collected from the medical records of adults with CP aged 18 years and over using the Rochester Health Status Survey IV (RHSS-IV). The RHSS-IV is a 58-item validated survey of health and functional status in adults with intellectual or developmental disabilities (IDD) (27). It was originally developed to support broad health services research and is composed of five sections (i) demographics, (ii) general health status, (iii) medical conditions, (iv) functional status and (v) health services utilization. The RHSS-IV was designed to examine a wide range of developmental conditions, including CP. However, information specific to CP, such as topographic type of CP, presence and degree of hypertonia (spasticity, dystonia, mixed) or Gross Motor Function Classification System (GMFCS) level were not available on the RHSS-IV. RHSS data abstraction Data abstraction closely followed procedures defined as optimal in the RHSS validation study (27). A nurse with specialization in physical disabilities collected data manually through chart review. Health conditions were identified from the problem list and past medical history. Data abstraction and chart review averaged about 60 min per record. Chart reviewed included an in-depth appraisal of notes and documentation from the PCP, physical therapist, occupational therapist, sub-specialists (e.g. physical medicine and rehabilitation physicians, orthopaedists, neurologists, gastroenterologists, urologists) and mental health therapists. The principal investigator, a physician with expertise in intellectual and developmental disabilities, oversaw the chart review process and was consulted for any questions pertaining to data collection. All data were double entered using Microsoft Access and the two datasets were then compared using SAS version 9.4. Any discrepancies in data entry were resolved using the paper survey. RHSS-IV variable creation Health conditions in the following broad categories were collected: heart and circulatory diseases, pulmonary diseases, endocrine/metabolic diseases, gastrointestinal diseases, neurologic diseases, genito-urinary and kidney diseases and musculoskeletal conditions. Functional ability was examined based on the ability to perform activities of daily living (ADLs) and the person’s level of walking independence. ADL’s were recorded as (i) independent, (ii) requiring supervision or verbal prompt, (iii) requiring physical assistance or (iv) totally dependent. Binary groups were subsequently created, one that was totally independent with ADLs and a second that required any amount of assistance. Walking was recorded as (i) walks independently in all settings; (ii) walks independently or with assistive device(s) in most settings; (iii) walks independently or with assistive device(s) in some settings and (iv) cannot walk independently or with assistive device(s) in any settings. Walking was dichotomized as ‘independent/mostly independent’ versus ‘non-ambulatory /some ambulation with assistance.’ Specific IQ was not available for the majority of records. Intellectual capacity was determined based on whether an intellectual disability was noted in the chart (yes/no). National health and nutrition examination survey (NHANES) and National health interview survey (NHIS) We used population-level data to serve as a point of reference for comparison to rates observed within adults with CP. Both NHANES and NHIS are national surveys administered by the National Center for Health Statistics (NCHS) and the Centers for Disease Control and Prevention (CDC). NHANES utilizes a multistage probability design that combines interviews and physical examinations to assess the health and nutritional status of the United States population in 2-year cycles. NHIS is a household-based survey designed to monitor the prevalence of a broad range of health conditions. Two cycles of NHANES (2011–2012, 2013–2014) were used to establish the prevalence of all health conditions except seizure and migraines, which were not contained within the NHANES datasets. Data on constipation were obtained from the 2009–2010 NHANES cycle. The NHIS 2015 dataset was used to estimate the prevalence of seizures and migraines in the general population. The data presented from NHANES and NHIS represents broad US population data, including those with CP. NHANES and NHIS variable creation The data abstracted from NHANES were based upon the question ‘Has a doctor or health professional ever told you that you had or have…?’ Tobacco/nicotine misuse was defined as using tobacco or nicotine within the last 5 days. Alcohol misuse was defined based on the question ‘Was there ever a time or times in your life when you drank four or more drinks of any kind of alcoholic beverage almost every day?’ Depression was determined by assessing variables in NHANES using the Patient Health Questionnaire (PHQ-9). The PHQ-9 is a validated, nine-item screening instrument that inquires about symptoms of depression on a scale of 0 to 3 (28). Consistent with prior literature and clinical practice, a score of 10 or higher was used to define depression (29). Statistical analysis All statistical analyses were carried out using SAS version 9.4 (SAS Institute Inc., Cary, NC). Within the RHSS sample of individuals with CP, confidence intervals around the point prevalence of health conditions were calculated using the Clopper–Pearson method (30,31). We calculated the point prevalence of health conditions in our national samples from NHANES and NHIS using survey function procedures to account for the multistage probability sampling design. The prevalence rates of health conditions in adults with CP were compared to the general population. To account for the difference in the survey methodology between the RHSS-IV, NHANES and NHIS, the prevalence rates were compared based on the difference in proportion and the calculated z-scores based on the variance. The difference between the two proportions was calculated along with the estimated standard errors for this difference. The difference was then normalized by using the estimated standard error to obtain a z-score. The z-score was then converted to a P-value for a two-tailed test by finding the probability of z. Logistic regression models were used to examine trends in prevalence in adults with CP across age groups while adjusting for gender. We compared proportions with chi-square test statistics for proportions and the Cochran–Armitage test for ordered proportions. Multivariate logistic regression models were used to examine the independent factors associated with walking and ADL status in two separate regression models. The dependent variables for the two regressions were (i) independence with all ADLs (eating, dressing, bathing, toileting) (yes/no); and (ii) independence or mostly independent with walking (yes/no). The independent variables included in the regression based on clinical significance were age group, gender and intellectual disability (yes/no). Health conditions were included in the model if their bivariate comparison showed a P value of less than or equal to 0.2. Human subjects/institutional review board review This study was approved by the University of Rochester Research Subjects Review Board and the protocols used by NHANES and NHIS were approved by the National Center for Health Statistics (NCHS) Institutional Review Board. Results Our sample of 229 adults with CP included a broad age distribution. A total of 24.5% (N = 56) of adults were ≤29 years of age, 17.9% (N = 41) were between 30 and 39 years, 22.7% (N = 51) were between 40 and 49 years, 17.9% (N = 41) were between 50 and 59 years and 17.5% (N = 40) were 60 years of age or over. The sample was predominantly (59.0%; N = 135) male and the majority (54.1%; N = 124) had an intellectual disability. Within this sample 44.1% (N = 101) lived in a supervised setting (i.e. group home), 39.3% (N = 90) lived with family and 16.6% (N = 38) were independent. Table 1 illustrates the point prevalence of health conditions in our cohort of adults with CP compared to data from NHANES and NHIS (‘the general population’). Compared to the general population, adults with CP had higher rates of seizure disorder, obesity and asthma across all ages. Adults with CP under 30 years of age had higher rates of hypertension (16.7 versus 5.6%; P = 0.04), urinary incontinence (41.7 versus 10.5%; P < 0.001) and depression (16.7 versus 6.9%; P = 0.07) compared to the general population. Adults with CP also had a higher prevalence of depression across all ages; but this finding was not consistently significant by age group. Adults with CP had a higher prevalence of hypertension across most age groups, except in the 30–39 year age group. In contrast, they demonstrated lower rates of alcohol misuse, tobacco/nicotine and sexually transmitted illnesses (STIs) compared to the general population. Table 1. Health conditions in adults with CP and in the general population from the RHSS-IV and National Health and Nutrition Examination Surveya 2011–2014 Health condition  18–29 years  30–39 years  40–49 years  50–59 years  >59 years  CPb (N = 56)  General populationa  P-Value  CPb (N = 41)  General populationa  P-Value  CPb (N = 51)  General populationa  P-Value  CPb (N = 41)  General populationb  P-Value  CPb (N = 40)  General populationa  P-Value  Neurologic   Seizure disorderc  44.6%  2.5%  <0.001  56.1%  2.0%  <0.001  39.2%  1.6%  <0.001  39.0%  2.3%  <0.001  30.0%  1.5%  <0.001   Migraine/severe Headachec  16.1%  17.1%  0.93  26.8%  19.4%  0.28  17.7%  18.0%  0.95  14.6%  15.8%  0.83  5.0%  8.2%  0.35  Gastrointestinal   Constipationd  3.6%  17.1%  <0.001  4.9%  23.9%  <0.001  2.0%  22.5%  <0.001  7.3%  77.5%  <0.001  5.0%  74.8%  <0.001   GERD  41.1%  —  —  34.1%  —  —  41.2%  —  —  39.0%  —  —  57.5%  —  —   Bowel obstruction  5.4%  —  —  4.9%  —  —  3.9%  —  —  2.4%  —  —  2.5%  —  —  Psychiatric   Depressione  16.1%  6.9%  0.07  17.1%  7.8%  0.13  37.3%  10.1%  <0.001  19.5%  10.2%  0.14  27.5%  5.7%  0.002   Anxiety disorder  7.1%  f  —  14.6%  f  —  23.5%  f  —  22.2%  f  —  16.7%  f  —   ADHD  8.9%  —  —  4.9%  —  —  2.0%  —  —  7.3%  —  —  0.0%  —  —   Schizophrenia/psychosis  1.8%  g  —  0.0%  g    2.0%  g  —  4.9%  g  —  10.0%  g  —  Heart and circulatory   Hypertension  16.1%  5.6%  0.04  12.2%  16.1%  0.47  37.3%  26.0%  0.11  48.8%  40.8%  0.33  80.0%  58.4%  0.001   Hyperlipidemia  7.1%  6.3%  0.82  0.0%  16.3%  <.001  23.5%  32.5%  0.17  29.3%  46.7%  0.02  45.0%  53.4%  0.29   Myocardial Infarction or  stroke  5.4%  0.6%  0.11  2.4%  0.7%  0.47  9.8%  1.9%  0.06  7.3%  5.5%  0.66  22.5%  14.8%  0.25  Pulmonary   Asthma  35.7%  18.4%  0.01  58.5%  14.0%  <0.001  60.8%  15.3%  <0.001  43.9%  12.4%  <0.001  45.0%  13.5%  <0.001   Allergies  37.5%  21.2%  0.03  48.8%  30.1%  0.11  58.8%  45.3%  0.13  39.0%  48.8%  0.29  42.5%  37.0%  0.55   COPDh  0.0%  0.2%  0.05  0.0%  0.4%  0.05  2.0%  1.5%  0.83  4.9%  4.8%  0.99  7.5%  7.7%  0.96  Endocrine   Diabetes  7.1%  0.5%  0.05  4.9%  2.4%  0.47  3.9%  6.5%  0.39  9.8%  12.3%  0.60  12.5%  19.1%  0.23   Hypothyroidi  7.1%  3.5%  0.30  9.8%  4.5%  0.26  9.8%  9.6%  0.97  17.1%  12.3%  0.43  17.5%  18.8%  0.84   Hyperthyroid  0.0%      0.0%      2.0%      0.0%      2.5%      Genito-urinary and kidney   Urinary incontinence  41.1%  10.5%  <0.001  43.9%  14.7%  <0.001  45.1%  25.8%  0.01  39.0%  33.2%  0.46  55.0%  42.5%  0.12   Chronic kidney disease  1.8%  1.1%  0.68  0.0%  1.9%  <0.001  3.9%  1.9%  0.46  2.4%  3.6%  0.70  0.9%  4.7%  0.94  Musculoskeletal   Osteoporosisj  10.7%  —  —  24.4%  —  —  9.8%  2.4%  0.08  22.0%  5.7%  0.01  8.3%  14.2%  <0.001  Substance use                                 Tobacco/nicotinek  3.6%  21.8%  <0.001  4.9%  26.3%  <0.001  11.8%  31.2%  <0.001  12.2%  26.9%  0.01  1.8%  13.3%  0.50   Alcohol misusel  0.0%  9.9%  <0.001  0.0%  15.6%  <0.001  0.0%  19.2%  <0.001  4.9%  19.3%  <0.001  2.5%  13.5%  <0.001  Infectious   STIm  1.8%  7.0%  0.02  9.8%  7.1%  0.58  3.9%  6.5%  0.40  4.9%  7.1%  0.56  2.5%  —  —  General   Obesity  37.5%  15.0%  <0.001  43.9%  31.8%  <0.001  47.1%  38.1%  <0.001  46.3%  40.8%  <0.001  37.5%  35.4%  <0.001  Health condition  18–29 years  30–39 years  40–49 years  50–59 years  >59 years  CPb (N = 56)  General populationa  P-Value  CPb (N = 41)  General populationa  P-Value  CPb (N = 51)  General populationa  P-Value  CPb (N = 41)  General populationb  P-Value  CPb (N = 40)  General populationa  P-Value  Neurologic   Seizure disorderc  44.6%  2.5%  <0.001  56.1%  2.0%  <0.001  39.2%  1.6%  <0.001  39.0%  2.3%  <0.001  30.0%  1.5%  <0.001   Migraine/severe Headachec  16.1%  17.1%  0.93  26.8%  19.4%  0.28  17.7%  18.0%  0.95  14.6%  15.8%  0.83  5.0%  8.2%  0.35  Gastrointestinal   Constipationd  3.6%  17.1%  <0.001  4.9%  23.9%  <0.001  2.0%  22.5%  <0.001  7.3%  77.5%  <0.001  5.0%  74.8%  <0.001   GERD  41.1%  —  —  34.1%  —  —  41.2%  —  —  39.0%  —  —  57.5%  —  —   Bowel obstruction  5.4%  —  —  4.9%  —  —  3.9%  —  —  2.4%  —  —  2.5%  —  —  Psychiatric   Depressione  16.1%  6.9%  0.07  17.1%  7.8%  0.13  37.3%  10.1%  <0.001  19.5%  10.2%  0.14  27.5%  5.7%  0.002   Anxiety disorder  7.1%  f  —  14.6%  f  —  23.5%  f  —  22.2%  f  —  16.7%  f  —   ADHD  8.9%  —  —  4.9%  —  —  2.0%  —  —  7.3%  —  —  0.0%  —  —   Schizophrenia/psychosis  1.8%  g  —  0.0%  g    2.0%  g  —  4.9%  g  —  10.0%  g  —  Heart and circulatory   Hypertension  16.1%  5.6%  0.04  12.2%  16.1%  0.47  37.3%  26.0%  0.11  48.8%  40.8%  0.33  80.0%  58.4%  0.001   Hyperlipidemia  7.1%  6.3%  0.82  0.0%  16.3%  <.001  23.5%  32.5%  0.17  29.3%  46.7%  0.02  45.0%  53.4%  0.29   Myocardial Infarction or  stroke  5.4%  0.6%  0.11  2.4%  0.7%  0.47  9.8%  1.9%  0.06  7.3%  5.5%  0.66  22.5%  14.8%  0.25  Pulmonary   Asthma  35.7%  18.4%  0.01  58.5%  14.0%  <0.001  60.8%  15.3%  <0.001  43.9%  12.4%  <0.001  45.0%  13.5%  <0.001   Allergies  37.5%  21.2%  0.03  48.8%  30.1%  0.11  58.8%  45.3%  0.13  39.0%  48.8%  0.29  42.5%  37.0%  0.55   COPDh  0.0%  0.2%  0.05  0.0%  0.4%  0.05  2.0%  1.5%  0.83  4.9%  4.8%  0.99  7.5%  7.7%  0.96  Endocrine   Diabetes  7.1%  0.5%  0.05  4.9%  2.4%  0.47  3.9%  6.5%  0.39  9.8%  12.3%  0.60  12.5%  19.1%  0.23   Hypothyroidi  7.1%  3.5%  0.30  9.8%  4.5%  0.26  9.8%  9.6%  0.97  17.1%  12.3%  0.43  17.5%  18.8%  0.84   Hyperthyroid  0.0%      0.0%      2.0%      0.0%      2.5%      Genito-urinary and kidney   Urinary incontinence  41.1%  10.5%  <0.001  43.9%  14.7%  <0.001  45.1%  25.8%  0.01  39.0%  33.2%  0.46  55.0%  42.5%  0.12   Chronic kidney disease  1.8%  1.1%  0.68  0.0%  1.9%  <0.001  3.9%  1.9%  0.46  2.4%  3.6%  0.70  0.9%  4.7%  0.94  Musculoskeletal   Osteoporosisj  10.7%  —  —  24.4%  —  —  9.8%  2.4%  0.08  22.0%  5.7%  0.01  8.3%  14.2%  <0.001  Substance use                                 Tobacco/nicotinek  3.6%  21.8%  <0.001  4.9%  26.3%  <0.001  11.8%  31.2%  <0.001  12.2%  26.9%  0.01  1.8%  13.3%  0.50   Alcohol misusel  0.0%  9.9%  <0.001  0.0%  15.6%  <0.001  0.0%  19.2%  <0.001  4.9%  19.3%  <0.001  2.5%  13.5%  <0.001  Infectious   STIm  1.8%  7.0%  0.02  9.8%  7.1%  0.58  3.9%  6.5%  0.40  4.9%  7.1%  0.56  2.5%  —  —  General   Obesity  37.5%  15.0%  <0.001  43.9%  31.8%  <0.001  47.1%  38.1%  <0.001  46.3%  40.8%  <0.001  37.5%  35.4%  <0.001  The bold indicates statistical significance. ADHD, attention deficit hyperactivity disorder; COPD, chronic obstructive lung disease; GERD, gastroesophageal disease; STI, indicates sexually transmitted illness. aAll data are from NHANES 2011–2012 and 2013–2014 unless otherwise specified. bConfidence intervals obtained using the Clopper–Pearson method due to small sample size. cData in general population data from NHIS. dData in general population from NHANES 2009–2010. eDepression in general population defined as having a PHQ-9 score of 10 or greater. MEC weights used to calculate weights estimates. fThe 12-month prevalence of generalized anxiety disorder among adults is estimated to be 2.9% In the United States. The lifetime risk for generalized anxiety disorder is estimated at 9.0%. gThe lifetime prevalence of schizophrenia ranges between 0.18 and 1.5%, with a mean report prevalence of 0.5% (32,33). hData for general population from NHANES 2013–2014 only. iData for general population includes any thyroid problem. jData from NHANES 2013–2014 only, questions only asked for persons aged 40 and above. kDefined in general population as tobacco or nicotine use in the last 5 days. lDefined in general population as drinking five or more drinks per day almost every day mDefined in general population as having gonorrhea, chlamydia or genital herpes in the past 12 month. View Large Table 1. Health conditions in adults with CP and in the general population from the RHSS-IV and National Health and Nutrition Examination Surveya 2011–2014 Health condition  18–29 years  30–39 years  40–49 years  50–59 years  >59 years  CPb (N = 56)  General populationa  P-Value  CPb (N = 41)  General populationa  P-Value  CPb (N = 51)  General populationa  P-Value  CPb (N = 41)  General populationb  P-Value  CPb (N = 40)  General populationa  P-Value  Neurologic   Seizure disorderc  44.6%  2.5%  <0.001  56.1%  2.0%  <0.001  39.2%  1.6%  <0.001  39.0%  2.3%  <0.001  30.0%  1.5%  <0.001   Migraine/severe Headachec  16.1%  17.1%  0.93  26.8%  19.4%  0.28  17.7%  18.0%  0.95  14.6%  15.8%  0.83  5.0%  8.2%  0.35  Gastrointestinal   Constipationd  3.6%  17.1%  <0.001  4.9%  23.9%  <0.001  2.0%  22.5%  <0.001  7.3%  77.5%  <0.001  5.0%  74.8%  <0.001   GERD  41.1%  —  —  34.1%  —  —  41.2%  —  —  39.0%  —  —  57.5%  —  —   Bowel obstruction  5.4%  —  —  4.9%  —  —  3.9%  —  —  2.4%  —  —  2.5%  —  —  Psychiatric   Depressione  16.1%  6.9%  0.07  17.1%  7.8%  0.13  37.3%  10.1%  <0.001  19.5%  10.2%  0.14  27.5%  5.7%  0.002   Anxiety disorder  7.1%  f  —  14.6%  f  —  23.5%  f  —  22.2%  f  —  16.7%  f  —   ADHD  8.9%  —  —  4.9%  —  —  2.0%  —  —  7.3%  —  —  0.0%  —  —   Schizophrenia/psychosis  1.8%  g  —  0.0%  g    2.0%  g  —  4.9%  g  —  10.0%  g  —  Heart and circulatory   Hypertension  16.1%  5.6%  0.04  12.2%  16.1%  0.47  37.3%  26.0%  0.11  48.8%  40.8%  0.33  80.0%  58.4%  0.001   Hyperlipidemia  7.1%  6.3%  0.82  0.0%  16.3%  <.001  23.5%  32.5%  0.17  29.3%  46.7%  0.02  45.0%  53.4%  0.29   Myocardial Infarction or  stroke  5.4%  0.6%  0.11  2.4%  0.7%  0.47  9.8%  1.9%  0.06  7.3%  5.5%  0.66  22.5%  14.8%  0.25  Pulmonary   Asthma  35.7%  18.4%  0.01  58.5%  14.0%  <0.001  60.8%  15.3%  <0.001  43.9%  12.4%  <0.001  45.0%  13.5%  <0.001   Allergies  37.5%  21.2%  0.03  48.8%  30.1%  0.11  58.8%  45.3%  0.13  39.0%  48.8%  0.29  42.5%  37.0%  0.55   COPDh  0.0%  0.2%  0.05  0.0%  0.4%  0.05  2.0%  1.5%  0.83  4.9%  4.8%  0.99  7.5%  7.7%  0.96  Endocrine   Diabetes  7.1%  0.5%  0.05  4.9%  2.4%  0.47  3.9%  6.5%  0.39  9.8%  12.3%  0.60  12.5%  19.1%  0.23   Hypothyroidi  7.1%  3.5%  0.30  9.8%  4.5%  0.26  9.8%  9.6%  0.97  17.1%  12.3%  0.43  17.5%  18.8%  0.84   Hyperthyroid  0.0%      0.0%      2.0%      0.0%      2.5%      Genito-urinary and kidney   Urinary incontinence  41.1%  10.5%  <0.001  43.9%  14.7%  <0.001  45.1%  25.8%  0.01  39.0%  33.2%  0.46  55.0%  42.5%  0.12   Chronic kidney disease  1.8%  1.1%  0.68  0.0%  1.9%  <0.001  3.9%  1.9%  0.46  2.4%  3.6%  0.70  0.9%  4.7%  0.94  Musculoskeletal   Osteoporosisj  10.7%  —  —  24.4%  —  —  9.8%  2.4%  0.08  22.0%  5.7%  0.01  8.3%  14.2%  <0.001  Substance use                                 Tobacco/nicotinek  3.6%  21.8%  <0.001  4.9%  26.3%  <0.001  11.8%  31.2%  <0.001  12.2%  26.9%  0.01  1.8%  13.3%  0.50   Alcohol misusel  0.0%  9.9%  <0.001  0.0%  15.6%  <0.001  0.0%  19.2%  <0.001  4.9%  19.3%  <0.001  2.5%  13.5%  <0.001  Infectious   STIm  1.8%  7.0%  0.02  9.8%  7.1%  0.58  3.9%  6.5%  0.40  4.9%  7.1%  0.56  2.5%  —  —  General   Obesity  37.5%  15.0%  <0.001  43.9%  31.8%  <0.001  47.1%  38.1%  <0.001  46.3%  40.8%  <0.001  37.5%  35.4%  <0.001  Health condition  18–29 years  30–39 years  40–49 years  50–59 years  >59 years  CPb (N = 56)  General populationa  P-Value  CPb (N = 41)  General populationa  P-Value  CPb (N = 51)  General populationa  P-Value  CPb (N = 41)  General populationb  P-Value  CPb (N = 40)  General populationa  P-Value  Neurologic   Seizure disorderc  44.6%  2.5%  <0.001  56.1%  2.0%  <0.001  39.2%  1.6%  <0.001  39.0%  2.3%  <0.001  30.0%  1.5%  <0.001   Migraine/severe Headachec  16.1%  17.1%  0.93  26.8%  19.4%  0.28  17.7%  18.0%  0.95  14.6%  15.8%  0.83  5.0%  8.2%  0.35  Gastrointestinal   Constipationd  3.6%  17.1%  <0.001  4.9%  23.9%  <0.001  2.0%  22.5%  <0.001  7.3%  77.5%  <0.001  5.0%  74.8%  <0.001   GERD  41.1%  —  —  34.1%  —  —  41.2%  —  —  39.0%  —  —  57.5%  —  —   Bowel obstruction  5.4%  —  —  4.9%  —  —  3.9%  —  —  2.4%  —  —  2.5%  —  —  Psychiatric   Depressione  16.1%  6.9%  0.07  17.1%  7.8%  0.13  37.3%  10.1%  <0.001  19.5%  10.2%  0.14  27.5%  5.7%  0.002   Anxiety disorder  7.1%  f  —  14.6%  f  —  23.5%  f  —  22.2%  f  —  16.7%  f  —   ADHD  8.9%  —  —  4.9%  —  —  2.0%  —  —  7.3%  —  —  0.0%  —  —   Schizophrenia/psychosis  1.8%  g  —  0.0%  g    2.0%  g  —  4.9%  g  —  10.0%  g  —  Heart and circulatory   Hypertension  16.1%  5.6%  0.04  12.2%  16.1%  0.47  37.3%  26.0%  0.11  48.8%  40.8%  0.33  80.0%  58.4%  0.001   Hyperlipidemia  7.1%  6.3%  0.82  0.0%  16.3%  <.001  23.5%  32.5%  0.17  29.3%  46.7%  0.02  45.0%  53.4%  0.29   Myocardial Infarction or  stroke  5.4%  0.6%  0.11  2.4%  0.7%  0.47  9.8%  1.9%  0.06  7.3%  5.5%  0.66  22.5%  14.8%  0.25  Pulmonary   Asthma  35.7%  18.4%  0.01  58.5%  14.0%  <0.001  60.8%  15.3%  <0.001  43.9%  12.4%  <0.001  45.0%  13.5%  <0.001   Allergies  37.5%  21.2%  0.03  48.8%  30.1%  0.11  58.8%  45.3%  0.13  39.0%  48.8%  0.29  42.5%  37.0%  0.55   COPDh  0.0%  0.2%  0.05  0.0%  0.4%  0.05  2.0%  1.5%  0.83  4.9%  4.8%  0.99  7.5%  7.7%  0.96  Endocrine   Diabetes  7.1%  0.5%  0.05  4.9%  2.4%  0.47  3.9%  6.5%  0.39  9.8%  12.3%  0.60  12.5%  19.1%  0.23   Hypothyroidi  7.1%  3.5%  0.30  9.8%  4.5%  0.26  9.8%  9.6%  0.97  17.1%  12.3%  0.43  17.5%  18.8%  0.84   Hyperthyroid  0.0%      0.0%      2.0%      0.0%      2.5%      Genito-urinary and kidney   Urinary incontinence  41.1%  10.5%  <0.001  43.9%  14.7%  <0.001  45.1%  25.8%  0.01  39.0%  33.2%  0.46  55.0%  42.5%  0.12   Chronic kidney disease  1.8%  1.1%  0.68  0.0%  1.9%  <0.001  3.9%  1.9%  0.46  2.4%  3.6%  0.70  0.9%  4.7%  0.94  Musculoskeletal   Osteoporosisj  10.7%  —  —  24.4%  —  —  9.8%  2.4%  0.08  22.0%  5.7%  0.01  8.3%  14.2%  <0.001  Substance use                                 Tobacco/nicotinek  3.6%  21.8%  <0.001  4.9%  26.3%  <0.001  11.8%  31.2%  <0.001  12.2%  26.9%  0.01  1.8%  13.3%  0.50   Alcohol misusel  0.0%  9.9%  <0.001  0.0%  15.6%  <0.001  0.0%  19.2%  <0.001  4.9%  19.3%  <0.001  2.5%  13.5%  <0.001  Infectious   STIm  1.8%  7.0%  0.02  9.8%  7.1%  0.58  3.9%  6.5%  0.40  4.9%  7.1%  0.56  2.5%  —  —  General   Obesity  37.5%  15.0%  <0.001  43.9%  31.8%  <0.001  47.1%  38.1%  <0.001  46.3%  40.8%  <0.001  37.5%  35.4%  <0.001  The bold indicates statistical significance. ADHD, attention deficit hyperactivity disorder; COPD, chronic obstructive lung disease; GERD, gastroesophageal disease; STI, indicates sexually transmitted illness. aAll data are from NHANES 2011–2012 and 2013–2014 unless otherwise specified. bConfidence intervals obtained using the Clopper–Pearson method due to small sample size. cData in general population data from NHIS. dData in general population from NHANES 2009–2010. eDepression in general population defined as having a PHQ-9 score of 10 or greater. MEC weights used to calculate weights estimates. fThe 12-month prevalence of generalized anxiety disorder among adults is estimated to be 2.9% In the United States. The lifetime risk for generalized anxiety disorder is estimated at 9.0%. gThe lifetime prevalence of schizophrenia ranges between 0.18 and 1.5%, with a mean report prevalence of 0.5% (32,33). hData for general population from NHANES 2013–2014 only. iData for general population includes any thyroid problem. jData from NHANES 2013–2014 only, questions only asked for persons aged 40 and above. kDefined in general population as tobacco or nicotine use in the last 5 days. lDefined in general population as drinking five or more drinks per day almost every day mDefined in general population as having gonorrhea, chlamydia or genital herpes in the past 12 month. View Large Table 2 depicts the trend in the prevalence of health conditions across the different age groups. Seizure disorder, constipation and depression remained consistent across age groups. The prevalence of hypertension, hyperlipidemia and osteoporosis increased across all age groups. Compared to younger adults aged 18–29, adults over the age of 59 with CP had a substantially greater prevalence of hypertension (AOR 23.2; 95% CI 7.9–67.9), hyperlipidemia (AOR 10.5; 95% CI 3.2–34.7) and osteoporosis (AOR7.9; 95% CI 2.7–22.6). Table 2. Health conditions across age groups in adults with CP from the RHSS-IV 2011–2014 Outcome  18–29 years AORa (N = 56)  30–39 years AORa (N = 41)  40–49 years AORa (N = 51)  50–59 years AORa (N = 41)  ≥60 years AORa (N = 40)  Neurologic   Seizure disorder (N = 96)  1.0  1.6 (0.7–3.6)  0.8 (0.4–1.7)  0.8 (0.3–1.7)  0.5 (0.2–1.2)   Migraine/severe headache (N = 37)  1.0  2.0 (0.7–5.4)  1.2 (0.4–3.2)  0.9 (0.3–2.8)  0.3 (0.06–1.4)  Psychiatric   Depression (N = 54)  1.0  1.1 (0.4–3.3)  3.4 (1.3–8.6)  1.3 (0.5–3.8)  2.2 (0.8–6.2)   Anxiety disorder (N = 36)  1.0  2.3 (0.6–8.6)  4.1 (1.2–13.6)  3.2 (0.9–11.5)  2.4 (0.6–9.1)  Heart and circulatory   MI or stroke (N = 21)  1.0  0.4 (0.05–4.5)  2.0 (0.4–8.6)  1.4 (0.3–7.4)  5.4 (1.3–21.6)   Hypertension (N = 85)  1.0  0.7 (0.2–2.4)  3.2 (1.2–8.1)  5.2 (2.0–13.5)  23.2 (7.9–67.9)   Hyperlipidemia (N = 46)  1.0  —  4.0 (1.2–13.3)  5.4 (1.6–18.2)  10.5 (3.2–34.7)  Pulmonary   Asthma (N = 111)  1.0  2.6 (1.1–5.9)  2.8 (1.3–6.3)  1.4 (0.6–3.3)  1.5 (0.7–3.5)   Allergies (N = 104)  1.0  1.6 (0.7–3.6)  2.4 (1.1–5.2)  1.1 (0.5–2.5)  1.3 (0.5–2.9)  Endocrine/metabolic   Hypothyroid (N = 27)  1.0  1.5 (0.3–6.3)  1.5 (0.4–5.9)  2.8 (0.8–10.5)  3.1 (0.8–11.6)  Urinary/renal   Incontinence (N = 102)  1.0  1.1 (0.5–2.6)  1.2 (0.5–2.6)  0.9 (0.4–2.1)  1.8 (0.8–4.1)  Gastrointestinal   GERD (N = 97)  1.0  0.8 (0.3–1.7)  1.0 (0.5–2.2)  0.9 (0.4–2.1)  2.1 (0.9–4.7)  Musculoskeletal   Osteoporosis (N = 49)  1.0  2.7 (0.9–8.3)  0.9 (0.3–3.2)  2.4 (0.8–7.3)  7.9 (2.7–22.6)  General   Obesity (N = 97)  1.0  1.4 (0.6–3.2)  1.6 (0.7–3.5)  1.5 (0.7–3.6)  1.1 (0.5–2.7)  Outcome  18–29 years AORa (N = 56)  30–39 years AORa (N = 41)  40–49 years AORa (N = 51)  50–59 years AORa (N = 41)  ≥60 years AORa (N = 40)  Neurologic   Seizure disorder (N = 96)  1.0  1.6 (0.7–3.6)  0.8 (0.4–1.7)  0.8 (0.3–1.7)  0.5 (0.2–1.2)   Migraine/severe headache (N = 37)  1.0  2.0 (0.7–5.4)  1.2 (0.4–3.2)  0.9 (0.3–2.8)  0.3 (0.06–1.4)  Psychiatric   Depression (N = 54)  1.0  1.1 (0.4–3.3)  3.4 (1.3–8.6)  1.3 (0.5–3.8)  2.2 (0.8–6.2)   Anxiety disorder (N = 36)  1.0  2.3 (0.6–8.6)  4.1 (1.2–13.6)  3.2 (0.9–11.5)  2.4 (0.6–9.1)  Heart and circulatory   MI or stroke (N = 21)  1.0  0.4 (0.05–4.5)  2.0 (0.4–8.6)  1.4 (0.3–7.4)  5.4 (1.3–21.6)   Hypertension (N = 85)  1.0  0.7 (0.2–2.4)  3.2 (1.2–8.1)  5.2 (2.0–13.5)  23.2 (7.9–67.9)   Hyperlipidemia (N = 46)  1.0  —  4.0 (1.2–13.3)  5.4 (1.6–18.2)  10.5 (3.2–34.7)  Pulmonary   Asthma (N = 111)  1.0  2.6 (1.1–5.9)  2.8 (1.3–6.3)  1.4 (0.6–3.3)  1.5 (0.7–3.5)   Allergies (N = 104)  1.0  1.6 (0.7–3.6)  2.4 (1.1–5.2)  1.1 (0.5–2.5)  1.3 (0.5–2.9)  Endocrine/metabolic   Hypothyroid (N = 27)  1.0  1.5 (0.3–6.3)  1.5 (0.4–5.9)  2.8 (0.8–10.5)  3.1 (0.8–11.6)  Urinary/renal   Incontinence (N = 102)  1.0  1.1 (0.5–2.6)  1.2 (0.5–2.6)  0.9 (0.4–2.1)  1.8 (0.8–4.1)  Gastrointestinal   GERD (N = 97)  1.0  0.8 (0.3–1.7)  1.0 (0.5–2.2)  0.9 (0.4–2.1)  2.1 (0.9–4.7)  Musculoskeletal   Osteoporosis (N = 49)  1.0  2.7 (0.9–8.3)  0.9 (0.3–3.2)  2.4 (0.8–7.3)  7.9 (2.7–22.6)  General   Obesity (N = 97)  1.0  1.4 (0.6–3.2)  1.6 (0.7–3.5)  1.5 (0.7–3.6)  1.1 (0.5–2.7)  ADHD, attention deficit hyperactivity disorder; GERD, gastroesophageal disease. aAdjusted for gender. View Large Table 2. Health conditions across age groups in adults with CP from the RHSS-IV 2011–2014 Outcome  18–29 years AORa (N = 56)  30–39 years AORa (N = 41)  40–49 years AORa (N = 51)  50–59 years AORa (N = 41)  ≥60 years AORa (N = 40)  Neurologic   Seizure disorder (N = 96)  1.0  1.6 (0.7–3.6)  0.8 (0.4–1.7)  0.8 (0.3–1.7)  0.5 (0.2–1.2)   Migraine/severe headache (N = 37)  1.0  2.0 (0.7–5.4)  1.2 (0.4–3.2)  0.9 (0.3–2.8)  0.3 (0.06–1.4)  Psychiatric   Depression (N = 54)  1.0  1.1 (0.4–3.3)  3.4 (1.3–8.6)  1.3 (0.5–3.8)  2.2 (0.8–6.2)   Anxiety disorder (N = 36)  1.0  2.3 (0.6–8.6)  4.1 (1.2–13.6)  3.2 (0.9–11.5)  2.4 (0.6–9.1)  Heart and circulatory   MI or stroke (N = 21)  1.0  0.4 (0.05–4.5)  2.0 (0.4–8.6)  1.4 (0.3–7.4)  5.4 (1.3–21.6)   Hypertension (N = 85)  1.0  0.7 (0.2–2.4)  3.2 (1.2–8.1)  5.2 (2.0–13.5)  23.2 (7.9–67.9)   Hyperlipidemia (N = 46)  1.0  —  4.0 (1.2–13.3)  5.4 (1.6–18.2)  10.5 (3.2–34.7)  Pulmonary   Asthma (N = 111)  1.0  2.6 (1.1–5.9)  2.8 (1.3–6.3)  1.4 (0.6–3.3)  1.5 (0.7–3.5)   Allergies (N = 104)  1.0  1.6 (0.7–3.6)  2.4 (1.1–5.2)  1.1 (0.5–2.5)  1.3 (0.5–2.9)  Endocrine/metabolic   Hypothyroid (N = 27)  1.0  1.5 (0.3–6.3)  1.5 (0.4–5.9)  2.8 (0.8–10.5)  3.1 (0.8–11.6)  Urinary/renal   Incontinence (N = 102)  1.0  1.1 (0.5–2.6)  1.2 (0.5–2.6)  0.9 (0.4–2.1)  1.8 (0.8–4.1)  Gastrointestinal   GERD (N = 97)  1.0  0.8 (0.3–1.7)  1.0 (0.5–2.2)  0.9 (0.4–2.1)  2.1 (0.9–4.7)  Musculoskeletal   Osteoporosis (N = 49)  1.0  2.7 (0.9–8.3)  0.9 (0.3–3.2)  2.4 (0.8–7.3)  7.9 (2.7–22.6)  General   Obesity (N = 97)  1.0  1.4 (0.6–3.2)  1.6 (0.7–3.5)  1.5 (0.7–3.6)  1.1 (0.5–2.7)  Outcome  18–29 years AORa (N = 56)  30–39 years AORa (N = 41)  40–49 years AORa (N = 51)  50–59 years AORa (N = 41)  ≥60 years AORa (N = 40)  Neurologic   Seizure disorder (N = 96)  1.0  1.6 (0.7–3.6)  0.8 (0.4–1.7)  0.8 (0.3–1.7)  0.5 (0.2–1.2)   Migraine/severe headache (N = 37)  1.0  2.0 (0.7–5.4)  1.2 (0.4–3.2)  0.9 (0.3–2.8)  0.3 (0.06–1.4)  Psychiatric   Depression (N = 54)  1.0  1.1 (0.4–3.3)  3.4 (1.3–8.6)  1.3 (0.5–3.8)  2.2 (0.8–6.2)   Anxiety disorder (N = 36)  1.0  2.3 (0.6–8.6)  4.1 (1.2–13.6)  3.2 (0.9–11.5)  2.4 (0.6–9.1)  Heart and circulatory   MI or stroke (N = 21)  1.0  0.4 (0.05–4.5)  2.0 (0.4–8.6)  1.4 (0.3–7.4)  5.4 (1.3–21.6)   Hypertension (N = 85)  1.0  0.7 (0.2–2.4)  3.2 (1.2–8.1)  5.2 (2.0–13.5)  23.2 (7.9–67.9)   Hyperlipidemia (N = 46)  1.0  —  4.0 (1.2–13.3)  5.4 (1.6–18.2)  10.5 (3.2–34.7)  Pulmonary   Asthma (N = 111)  1.0  2.6 (1.1–5.9)  2.8 (1.3–6.3)  1.4 (0.6–3.3)  1.5 (0.7–3.5)   Allergies (N = 104)  1.0  1.6 (0.7–3.6)  2.4 (1.1–5.2)  1.1 (0.5–2.5)  1.3 (0.5–2.9)  Endocrine/metabolic   Hypothyroid (N = 27)  1.0  1.5 (0.3–6.3)  1.5 (0.4–5.9)  2.8 (0.8–10.5)  3.1 (0.8–11.6)  Urinary/renal   Incontinence (N = 102)  1.0  1.1 (0.5–2.6)  1.2 (0.5–2.6)  0.9 (0.4–2.1)  1.8 (0.8–4.1)  Gastrointestinal   GERD (N = 97)  1.0  0.8 (0.3–1.7)  1.0 (0.5–2.2)  0.9 (0.4–2.1)  2.1 (0.9–4.7)  Musculoskeletal   Osteoporosis (N = 49)  1.0  2.7 (0.9–8.3)  0.9 (0.3–3.2)  2.4 (0.8–7.3)  7.9 (2.7–22.6)  General   Obesity (N = 97)  1.0  1.4 (0.6–3.2)  1.6 (0.7–3.5)  1.5 (0.7–3.6)  1.1 (0.5–2.7)  ADHD, attention deficit hyperactivity disorder; GERD, gastroesophageal disease. aAdjusted for gender. View Large Fewer than half of the participants were independent with all of the activities of daily living (ADL) (Table 3). The percent of those reporting independence with all ADLs decreased from 35.7% in those aged 18–29 years of age to 22.5% in those 59 and over. Adjusting for age, gender and intellectual status, several comorbidities were associated with lower overall functional self-care or walking status, including seizure disorder, urinary incontinence and gastroesophageal reflux disease (GERD) (Table 4). Hypertension, hyperlipidemia, hypothyroidism, myocardial infraction/stroke and diabetes were not associated with functional status or walking status. Table 3. Functional status and independence with ADLs in adults with CP from the RHSS-IV 2011–2014 Activity  18–29 years N = 56 (%)  30–39 years N = 41 (%)  40–49 years N = 51 (%)  50–59 years N = 41 (%)  ≥60 years N = 40 (%)  Walking status   Independent/mostly independent  48.2  58.5  62.8  63.4  40.0   Nonambulatory/some ambulation with assistance  51.8  41.5  37.3  36.6  60.0  Independent with all ADLs  35.7  41.5  31.4  36.6  22.5  Eating   Independent  39.3  41.5  35.3  36.5  25.0   Supervision or verbal prompt  21.4  43.9  54.9  48.8  62.5   Requires assistance or totally dependent  39.3  14.6  9.8  14.6  12.5  Dressing   Independent  37.5  41.5  33.3  36.6  22.5   Supervision or verbal prompt  23.2  39.0  54.9  43.9  50.0   Requires assistance or totally dependent  39.3  19.5  11.8  19.5  27.5  Bathing and washing   Independent  39.3  41.5  33.3  37.5  22.5   Supervision or verbal prompt  7.1  19.5  27.5  30.0  20.0   Requires assistance or totally dependent  53.6  39.0  39.2  32.5  57.5  Toileting   Independent  39.3  41.5  35.3  39.0  25.0   Supervision or verbal prompt  19.6  39.0  52.9  41.5  47.5   Requires assistance or totally dependent  41.1  19.5  11.8  19.5  27.5  Activity  18–29 years N = 56 (%)  30–39 years N = 41 (%)  40–49 years N = 51 (%)  50–59 years N = 41 (%)  ≥60 years N = 40 (%)  Walking status   Independent/mostly independent  48.2  58.5  62.8  63.4  40.0   Nonambulatory/some ambulation with assistance  51.8  41.5  37.3  36.6  60.0  Independent with all ADLs  35.7  41.5  31.4  36.6  22.5  Eating   Independent  39.3  41.5  35.3  36.5  25.0   Supervision or verbal prompt  21.4  43.9  54.9  48.8  62.5   Requires assistance or totally dependent  39.3  14.6  9.8  14.6  12.5  Dressing   Independent  37.5  41.5  33.3  36.6  22.5   Supervision or verbal prompt  23.2  39.0  54.9  43.9  50.0   Requires assistance or totally dependent  39.3  19.5  11.8  19.5  27.5  Bathing and washing   Independent  39.3  41.5  33.3  37.5  22.5   Supervision or verbal prompt  7.1  19.5  27.5  30.0  20.0   Requires assistance or totally dependent  53.6  39.0  39.2  32.5  57.5  Toileting   Independent  39.3  41.5  35.3  39.0  25.0   Supervision or verbal prompt  19.6  39.0  52.9  41.5  47.5   Requires assistance or totally dependent  41.1  19.5  11.8  19.5  27.5  View Large Table 3. Functional status and independence with ADLs in adults with CP from the RHSS-IV 2011–2014 Activity  18–29 years N = 56 (%)  30–39 years N = 41 (%)  40–49 years N = 51 (%)  50–59 years N = 41 (%)  ≥60 years N = 40 (%)  Walking status   Independent/mostly independent  48.2  58.5  62.8  63.4  40.0   Nonambulatory/some ambulation with assistance  51.8  41.5  37.3  36.6  60.0  Independent with all ADLs  35.7  41.5  31.4  36.6  22.5  Eating   Independent  39.3  41.5  35.3  36.5  25.0   Supervision or verbal prompt  21.4  43.9  54.9  48.8  62.5   Requires assistance or totally dependent  39.3  14.6  9.8  14.6  12.5  Dressing   Independent  37.5  41.5  33.3  36.6  22.5   Supervision or verbal prompt  23.2  39.0  54.9  43.9  50.0   Requires assistance or totally dependent  39.3  19.5  11.8  19.5  27.5  Bathing and washing   Independent  39.3  41.5  33.3  37.5  22.5   Supervision or verbal prompt  7.1  19.5  27.5  30.0  20.0   Requires assistance or totally dependent  53.6  39.0  39.2  32.5  57.5  Toileting   Independent  39.3  41.5  35.3  39.0  25.0   Supervision or verbal prompt  19.6  39.0  52.9  41.5  47.5   Requires assistance or totally dependent  41.1  19.5  11.8  19.5  27.5  Activity  18–29 years N = 56 (%)  30–39 years N = 41 (%)  40–49 years N = 51 (%)  50–59 years N = 41 (%)  ≥60 years N = 40 (%)  Walking status   Independent/mostly independent  48.2  58.5  62.8  63.4  40.0   Nonambulatory/some ambulation with assistance  51.8  41.5  37.3  36.6  60.0  Independent with all ADLs  35.7  41.5  31.4  36.6  22.5  Eating   Independent  39.3  41.5  35.3  36.5  25.0   Supervision or verbal prompt  21.4  43.9  54.9  48.8  62.5   Requires assistance or totally dependent  39.3  14.6  9.8  14.6  12.5  Dressing   Independent  37.5  41.5  33.3  36.6  22.5   Supervision or verbal prompt  23.2  39.0  54.9  43.9  50.0   Requires assistance or totally dependent  39.3  19.5  11.8  19.5  27.5  Bathing and washing   Independent  39.3  41.5  33.3  37.5  22.5   Supervision or verbal prompt  7.1  19.5  27.5  30.0  20.0   Requires assistance or totally dependent  53.6  39.0  39.2  32.5  57.5  Toileting   Independent  39.3  41.5  35.3  39.0  25.0   Supervision or verbal prompt  19.6  39.0  52.9  41.5  47.5   Requires assistance or totally dependent  41.1  19.5  11.8  19.5  27.5  View Large Table 4. Adults with cerebral palsy independent with activities of daily living and independent or mostly independent with walking from the RHSS-IV 2011–2014 Factor  ADL  Walking  Independent ADLsa (%)  P†  AORb (95% CI)  Independent/mostly walking* (%)  P†  AORc (95% CI)  Age    0.19d      0.81d     18–29 (N = 56)  35.7    1.0  48.2    1.0   30–39 (N = 41)  41.5    1.8 (0.7–5.1)  58.5    1.7 (0.7–3.9)   40–49 (N = 51)  31.4    0.7 (0.3–1.9)  62.8    1.8 (0.8–4.1)   50–59 (N = 41)  36.6    0.6 (0.2–1.8)  63.4    1.6 (0.7–3.8)   ≥60 (N = 40)  22.5    0.3 (0.1–1.8)  40.0    0.6 (0.2–1.4)  Gender    0.69      0.93     Male (N = 135)  32.6    1.0  54.8    1.0   Female (N = 94)  35.1    1.0 (0.5–1.8)  54.3    0.9 (0.5–1.6)  Intellectually disabled    <0.001      0.09     No (N = 105)  59.1    1.0  85.7    1.0   Yes (N = 124)  12.1    0.1 (0.03–0.1)  53.6    0.3 (0.2–0.6)  Health conditions               Seizure disorder    <0.001      <0.001      No (N = 133)  43.6    1.0  63.9    1.0    Yes (N = 96)  19.8    0.4 (0.2–0.8)  41.7    0.4 (0.2–0.8)   Urinary incontinence    <0.001      <0.001      No (N = 127)  55.9    1.0  77.2    1.0    Yes (N = 102)  5.9    0.1 (0.02–0.2)  26.5    0.1 (0.1–0.2)   GERD    0.007      <0.001      No (N = 132)  40.9    1.0  66.7    1.0    Yes (N = 97)  23.7    0.4 (0.2–0.8)  38.1    0.3 (0.2–0.5)   Anxiety    0.02      0.01      No (N = 193)  30.6    1.0  50.8    1.0    Yes (N = 36)  50.0    2.8 (1.2–7.0)  75.0    2.6 (1.1–6.1)   Depression    0.05      0.43      No (N = 175)  30.3    1.0  53.1    1.0    Yes (N = 54)  44.4    1.2 (0.6–2.6)  59.3    —   Migraines    <0.001      0.01      No (N = 192)  28.7    1.0  51.0    1.0    Yes (N = 37)  59.5    1.8 (0.8–4.2)  73.0    1.8 (0.8–4.1)  Factor  ADL  Walking  Independent ADLsa (%)  P†  AORb (95% CI)  Independent/mostly walking* (%)  P†  AORc (95% CI)  Age    0.19d      0.81d     18–29 (N = 56)  35.7    1.0  48.2    1.0   30–39 (N = 41)  41.5    1.8 (0.7–5.1)  58.5    1.7 (0.7–3.9)   40–49 (N = 51)  31.4    0.7 (0.3–1.9)  62.8    1.8 (0.8–4.1)   50–59 (N = 41)  36.6    0.6 (0.2–1.8)  63.4    1.6 (0.7–3.8)   ≥60 (N = 40)  22.5    0.3 (0.1–1.8)  40.0    0.6 (0.2–1.4)  Gender    0.69      0.93     Male (N = 135)  32.6    1.0  54.8    1.0   Female (N = 94)  35.1    1.0 (0.5–1.8)  54.3    0.9 (0.5–1.6)  Intellectually disabled    <0.001      0.09     No (N = 105)  59.1    1.0  85.7    1.0   Yes (N = 124)  12.1    0.1 (0.03–0.1)  53.6    0.3 (0.2–0.6)  Health conditions               Seizure disorder    <0.001      <0.001      No (N = 133)  43.6    1.0  63.9    1.0    Yes (N = 96)  19.8    0.4 (0.2–0.8)  41.7    0.4 (0.2–0.8)   Urinary incontinence    <0.001      <0.001      No (N = 127)  55.9    1.0  77.2    1.0    Yes (N = 102)  5.9    0.1 (0.02–0.2)  26.5    0.1 (0.1–0.2)   GERD    0.007      <0.001      No (N = 132)  40.9    1.0  66.7    1.0    Yes (N = 97)  23.7    0.4 (0.2–0.8)  38.1    0.3 (0.2–0.5)   Anxiety    0.02      0.01      No (N = 193)  30.6    1.0  50.8    1.0    Yes (N = 36)  50.0    2.8 (1.2–7.0)  75.0    2.6 (1.1–6.1)   Depression    0.05      0.43      No (N = 175)  30.3    1.0  53.1    1.0    Yes (N = 54)  44.4    1.2 (0.6–2.6)  59.3    —   Migraines    <0.001      0.01      No (N = 192)  28.7    1.0  51.0    1.0    Yes (N = 37)  59.5    1.8 (0.8–4.2)  73.0    1.8 (0.8–4.1)  aPercent of adults who are independent with all ADLs (eating, dressing, bathing and toileting). bLogistic model includes age, gender, ID level and individually with health conditions that have a P < 0.2 on bivariate comparison (GERD, seizure disorder, migraines, anxiety, depression and urinary incontinence). cLogistic model includes age, gender, ID level, and individually with health conditions that have a P < 0.2 on bivariate comparison (GERD, seizure disorder, migraines, anxiety and urinary incontinence). dCochran–Armitage trend test. †Chi-square test unless otherwise specified. View Large Table 4. Adults with cerebral palsy independent with activities of daily living and independent or mostly independent with walking from the RHSS-IV 2011–2014 Factor  ADL  Walking  Independent ADLsa (%)  P†  AORb (95% CI)  Independent/mostly walking* (%)  P†  AORc (95% CI)  Age    0.19d      0.81d     18–29 (N = 56)  35.7    1.0  48.2    1.0   30–39 (N = 41)  41.5    1.8 (0.7–5.1)  58.5    1.7 (0.7–3.9)   40–49 (N = 51)  31.4    0.7 (0.3–1.9)  62.8    1.8 (0.8–4.1)   50–59 (N = 41)  36.6    0.6 (0.2–1.8)  63.4    1.6 (0.7–3.8)   ≥60 (N = 40)  22.5    0.3 (0.1–1.8)  40.0    0.6 (0.2–1.4)  Gender    0.69      0.93     Male (N = 135)  32.6    1.0  54.8    1.0   Female (N = 94)  35.1    1.0 (0.5–1.8)  54.3    0.9 (0.5–1.6)  Intellectually disabled    <0.001      0.09     No (N = 105)  59.1    1.0  85.7    1.0   Yes (N = 124)  12.1    0.1 (0.03–0.1)  53.6    0.3 (0.2–0.6)  Health conditions               Seizure disorder    <0.001      <0.001      No (N = 133)  43.6    1.0  63.9    1.0    Yes (N = 96)  19.8    0.4 (0.2–0.8)  41.7    0.4 (0.2–0.8)   Urinary incontinence    <0.001      <0.001      No (N = 127)  55.9    1.0  77.2    1.0    Yes (N = 102)  5.9    0.1 (0.02–0.2)  26.5    0.1 (0.1–0.2)   GERD    0.007      <0.001      No (N = 132)  40.9    1.0  66.7    1.0    Yes (N = 97)  23.7    0.4 (0.2–0.8)  38.1    0.3 (0.2–0.5)   Anxiety    0.02      0.01      No (N = 193)  30.6    1.0  50.8    1.0    Yes (N = 36)  50.0    2.8 (1.2–7.0)  75.0    2.6 (1.1–6.1)   Depression    0.05      0.43      No (N = 175)  30.3    1.0  53.1    1.0    Yes (N = 54)  44.4    1.2 (0.6–2.6)  59.3    —   Migraines    <0.001      0.01      No (N = 192)  28.7    1.0  51.0    1.0    Yes (N = 37)  59.5    1.8 (0.8–4.2)  73.0    1.8 (0.8–4.1)  Factor  ADL  Walking  Independent ADLsa (%)  P†  AORb (95% CI)  Independent/mostly walking* (%)  P†  AORc (95% CI)  Age    0.19d      0.81d     18–29 (N = 56)  35.7    1.0  48.2    1.0   30–39 (N = 41)  41.5    1.8 (0.7–5.1)  58.5    1.7 (0.7–3.9)   40–49 (N = 51)  31.4    0.7 (0.3–1.9)  62.8    1.8 (0.8–4.1)   50–59 (N = 41)  36.6    0.6 (0.2–1.8)  63.4    1.6 (0.7–3.8)   ≥60 (N = 40)  22.5    0.3 (0.1–1.8)  40.0    0.6 (0.2–1.4)  Gender    0.69      0.93     Male (N = 135)  32.6    1.0  54.8    1.0   Female (N = 94)  35.1    1.0 (0.5–1.8)  54.3    0.9 (0.5–1.6)  Intellectually disabled    <0.001      0.09     No (N = 105)  59.1    1.0  85.7    1.0   Yes (N = 124)  12.1    0.1 (0.03–0.1)  53.6    0.3 (0.2–0.6)  Health conditions               Seizure disorder    <0.001      <0.001      No (N = 133)  43.6    1.0  63.9    1.0    Yes (N = 96)  19.8    0.4 (0.2–0.8)  41.7    0.4 (0.2–0.8)   Urinary incontinence    <0.001      <0.001      No (N = 127)  55.9    1.0  77.2    1.0    Yes (N = 102)  5.9    0.1 (0.02–0.2)  26.5    0.1 (0.1–0.2)   GERD    0.007      <0.001      No (N = 132)  40.9    1.0  66.7    1.0    Yes (N = 97)  23.7    0.4 (0.2–0.8)  38.1    0.3 (0.2–0.5)   Anxiety    0.02      0.01      No (N = 193)  30.6    1.0  50.8    1.0    Yes (N = 36)  50.0    2.8 (1.2–7.0)  75.0    2.6 (1.1–6.1)   Depression    0.05      0.43      No (N = 175)  30.3    1.0  53.1    1.0    Yes (N = 54)  44.4    1.2 (0.6–2.6)  59.3    —   Migraines    <0.001      0.01      No (N = 192)  28.7    1.0  51.0    1.0    Yes (N = 37)  59.5    1.8 (0.8–4.2)  73.0    1.8 (0.8–4.1)  aPercent of adults who are independent with all ADLs (eating, dressing, bathing and toileting). bLogistic model includes age, gender, ID level and individually with health conditions that have a P < 0.2 on bivariate comparison (GERD, seizure disorder, migraines, anxiety, depression and urinary incontinence). cLogistic model includes age, gender, ID level, and individually with health conditions that have a P < 0.2 on bivariate comparison (GERD, seizure disorder, migraines, anxiety and urinary incontinence). dCochran–Armitage trend test. †Chi-square test unless otherwise specified. View Large Table 5 demonstrates health care utilization stratified by age. All age groups reported greater use of primary care services compared to use of the ED. Both primary care and ED utilization increased with advancing age group. In adults aged 60 and over, 42.5% reported seeing a neurologist, 47.5% reported visiting a physical therapist, 20.0% reported visiting an occupational therapist and 20.0% reported seeing a psychiatrist in the last 24 months. Table 5. Health care utilization by individuals with CP by age groups from the RRHS-IV 2011–2014 Utilization in the last 24 months  18–29 years N = 56 (%)  30–39 years N = 41 (%)  40–49 years N = 51 (%)  50–59 years N = 41 (%)  ≥60 years N = 40 (%)  Number of primary care visits   None  26.8  22.0  7.8  12.2  7.5   1 or 2  23.3  39.0  43.1  34.2  30.0   3 or more  50.0  39.0  49.0  53.7  62.5  Number of ED visits   None  64.3  51.2  68.6  70.7  50.0   1 or 2  23.2  41.5  25.5  22.0  35.0   3 or more  12.5  7.3  5.9  7.3  15.0  Number of specialty care visits   None  14.3  17.1  15.7  14.6  2.5   Psychiatrist  16.1  17.1  21.6  24.4  20.0   Psychologist  3.6  4.9  0.0  4.9  0.0   Neurologist  37.5  48.8  27.5  31.7  42.5   Orthopaedic  17.9  22.0  21.6  17.1  30.0   Physical therapist  48.2  34.2  31.4  34.2  47.5   Occupational therapist  28.6  17.1  17.7  14.6  20.0   Speech pathologist  14.3  9.8  9.8  0.0  5.0   Podiatrist  7.1  9.8  7.8  14.6  22.5   Other  48.2  22.0  39.2  22.2  52.5  Utilization in the last 24 months  18–29 years N = 56 (%)  30–39 years N = 41 (%)  40–49 years N = 51 (%)  50–59 years N = 41 (%)  ≥60 years N = 40 (%)  Number of primary care visits   None  26.8  22.0  7.8  12.2  7.5   1 or 2  23.3  39.0  43.1  34.2  30.0   3 or more  50.0  39.0  49.0  53.7  62.5  Number of ED visits   None  64.3  51.2  68.6  70.7  50.0   1 or 2  23.2  41.5  25.5  22.0  35.0   3 or more  12.5  7.3  5.9  7.3  15.0  Number of specialty care visits   None  14.3  17.1  15.7  14.6  2.5   Psychiatrist  16.1  17.1  21.6  24.4  20.0   Psychologist  3.6  4.9  0.0  4.9  0.0   Neurologist  37.5  48.8  27.5  31.7  42.5   Orthopaedic  17.9  22.0  21.6  17.1  30.0   Physical therapist  48.2  34.2  31.4  34.2  47.5   Occupational therapist  28.6  17.1  17.7  14.6  20.0   Speech pathologist  14.3  9.8  9.8  0.0  5.0   Podiatrist  7.1  9.8  7.8  14.6  22.5   Other  48.2  22.0  39.2  22.2  52.5  View Large Table 5. Health care utilization by individuals with CP by age groups from the RRHS-IV 2011–2014 Utilization in the last 24 months  18–29 years N = 56 (%)  30–39 years N = 41 (%)  40–49 years N = 51 (%)  50–59 years N = 41 (%)  ≥60 years N = 40 (%)  Number of primary care visits   None  26.8  22.0  7.8  12.2  7.5   1 or 2  23.3  39.0  43.1  34.2  30.0   3 or more  50.0  39.0  49.0  53.7  62.5  Number of ED visits   None  64.3  51.2  68.6  70.7  50.0   1 or 2  23.2  41.5  25.5  22.0  35.0   3 or more  12.5  7.3  5.9  7.3  15.0  Number of specialty care visits   None  14.3  17.1  15.7  14.6  2.5   Psychiatrist  16.1  17.1  21.6  24.4  20.0   Psychologist  3.6  4.9  0.0  4.9  0.0   Neurologist  37.5  48.8  27.5  31.7  42.5   Orthopaedic  17.9  22.0  21.6  17.1  30.0   Physical therapist  48.2  34.2  31.4  34.2  47.5   Occupational therapist  28.6  17.1  17.7  14.6  20.0   Speech pathologist  14.3  9.8  9.8  0.0  5.0   Podiatrist  7.1  9.8  7.8  14.6  22.5   Other  48.2  22.0  39.2  22.2  52.5  Utilization in the last 24 months  18–29 years N = 56 (%)  30–39 years N = 41 (%)  40–49 years N = 51 (%)  50–59 years N = 41 (%)  ≥60 years N = 40 (%)  Number of primary care visits   None  26.8  22.0  7.8  12.2  7.5   1 or 2  23.3  39.0  43.1  34.2  30.0   3 or more  50.0  39.0  49.0  53.7  62.5  Number of ED visits   None  64.3  51.2  68.6  70.7  50.0   1 or 2  23.2  41.5  25.5  22.0  35.0   3 or more  12.5  7.3  5.9  7.3  15.0  Number of specialty care visits   None  14.3  17.1  15.7  14.6  2.5   Psychiatrist  16.1  17.1  21.6  24.4  20.0   Psychologist  3.6  4.9  0.0  4.9  0.0   Neurologist  37.5  48.8  27.5  31.7  42.5   Orthopaedic  17.9  22.0  21.6  17.1  30.0   Physical therapist  48.2  34.2  31.4  34.2  47.5   Occupational therapist  28.6  17.1  17.7  14.6  20.0   Speech pathologist  14.3  9.8  9.8  0.0  5.0   Podiatrist  7.1  9.8  7.8  14.6  22.5   Other  48.2  22.0  39.2  22.2  52.5  View Large Discussion Most adults with CP are living into older adulthood and receive a substantial amount of their care from PCPs, highlighting the importance of physicians to be skilled at providing care to adults with CP. This cross-sectional study of 229 adults with CP identified high rates of seizure disorder, hypertension, depression and anxiety. We also identified multiple health conditions common in the general population and associated changes in functional status. Therefore, comprehensive care of adults with CP must address health conditions specifically associated with CP, conditions common with aging and evolving changes in functional status. Mortality records reveal that death due to heart disease is higher among adults with CP compared to the general population (34). We found that hypertension, hyperlipidemia, myocardial infarction and stroke all increased in prevalence across the advancing age groups of adults with CP. We also found high rates of hypertension in adults with CP. Our results support prior findings of high rates of obesity and metabolic syndrome in adults with CP (10,11,13,16), emphasizing the potential association of cardiac risk factors and CP. Although the predominance of evidence support these associations, it is important to acknowledge that measurement inaccuracies in blood pressure related to spasticity are commonly seen in CP. In total, the increased rates of hypertension, metabolic syndrome and cardiovascular risk factors all point to the silent threat that hypertension poses to adults with CP (13,16). This association between hypertension, cardiovascular disease and CP requires further evaluation to better elucidate potential physiologic mechanisms, and possible areas of early recognition and intervention. We also identified a high prevalence of anxiety and depression in adults with CP. Mood disorders have been well described among people with intellectual and developmental disabilities, but depression and anxiety are less well documented in adults with CP (35–37). A study from the Netherlands similarly found an increased prevalence of depressive symptoms in adults with CP compared to the Dutch population (15). It is important for PCPs to recognize any underlying mood disorders. It is interesting to note that, even in the oldest age groups, only around 20% had seen a psychiatrist in the past 24 months. This further reinforces the need to address any evolving mental health conditions within primary care. Depression is a potentially treatable conditions and treatment may offer an opportunity to improve health and physical functioning in adults with CP. In our study, adults with CP had significantly increased rates of seizure disorders compared to the general population across all age groups, similar to prior studies (38). The higher prevalence of seizures disorders is particularly important to recognize, manage and monitor given its association with increased mortality, increased inpatient admissions and decreased functional status (39,40). Respiratory illnesses are also a leading cause of hospitalization and a significant contributor to excess mortality in CP (10,34,41). Consistent with a prior study, we found higher rates of asthma in adults with CP across all age groups (11). It is possible that recurrent aspiration events may contribute to increased bronchospasm. It is therefore important for PCPs to recognize asthma and possible aspiration events. Adults with CP were also found to have several health conditions that are commonly seen in the general population with aging, including osteoporosis, hyperlipidemia and hypothyroidism. Commonly occurring conditions frequently go undetected in persons with developmental disabilities due to barriers to accessing health care, receiving treatments and with communication regarding health conditions (42–48). Clinical recognition of these conditions and open communication is critical to improving general health and providing comprehensive care to adults with CP. In contrast to other conditions, we found a decreased prevalence of tobacco dependence and alcohol misuse in adults with CP. This may be a result of providers being less likely to inquire about substance use in this population (49). It is also possible that exposures to these substances are limited either due to the condition itself or social consequences of the condition. Similarly, we found that young adults aged 18–29 with CP had lower rates of STIs compared to the general population. These rates increased, however, in adults with CP aged 30–59 to rates similar to the general population. While the reasons are not clear, it is possible that sexual activity may be delayed in adults with CP compared to the general population. It remains important for PCPs to query their adult patients with CP about sexual practices and symptoms of STIs. Functional self-care and ambulation in adults with CP was found to decrease with advancing age and the majority of the sample required at least some assistance with basic ADLs at all ages. We further found functional status was adversely associated with only a few health conditions, suggesting that level of functional independence may be generally independent of many health conditions. The presence of a seizure disorder or urinary incontinence was associated with lower independence in ADLs and mobility, likely related to the direct limitations imparted by these conditions. The presence of an intellectual disability was also associated with lower independence in ADLs and mobility, likely reflecting greater overall impairments. Assessing and working to optimize functional status is an important component of care that is shared across multiple specialties. We found that visits to physical therapists were common across all age groups, but visits to occupational therapists and speech pathologists were substantially less frequent. Ensuring adequate access to physical therapists, occupational therapists and physical medicine and rehabilitation providers is an important component of the comprehensive care necessary to optimize functional status. Access to primary care is also essential to address health conditions and functional status. In our study population, primary care utilization remained greater than ED use across all age groups. Prior literature has demonstrated that adults with physically disabling conditions from childhood require frequent services, are less likely to receive preventive care, and frequently have unmet health care needs (21–23,50). Coordination of care with an interdisciplinary approach is essential to ensure appropriate ambulatory care, address unmet health care needs and reduce unnecessary ED utilization (20,22,23,51). This cross-sectional study has several limitations. Although the generalizability of these findings is supported by the broad source of data across 35 practices and 5 counties, the fact that the network is part of a single academic institution warrants caution. It is possible that selection bias from a regional and academic network may have influenced the results and overall generalizability. This may have resulted in a cohort with higher medical acuity and more complex needs, or may have missed conditions with lower prevalence (52). Our sample was mainly male, consistent with the gender differences seen in CP (4,53). Health information may also have been missed if it was underreported in chart reviews. Health status, functional status and intellectual capacity were determined by an in-depth review of notes and documentation from the PCP, physical/occupational therapists, sub-specialists and mental health therapists, but underreporting may still occur. Unfortunately, we do not have specific information about the GMFCS level, the topographic type of CP or specific IQ level. Conclusions Within our cohort, adults with CP had an increased prevalence of seizures disorders, hypertension, asthma, depression and obesity compared to the general population. Several of these conditions are associated with increased mortality and loss of functional status, and thus it is imperative to recognize and treat them accordingly. Adults with CP also develop many health conditions commonly seen in the general population with advancing age. Health conditions frequently go undetected in persons with developmental disabilities. Therefore, clinicians must ensure that adults with CP are screened and treated not just for conditions associated with CP, but also conditions that are common with aging in general. Declaration Funding: This research was supported in part by a sub-contract to the University of Rochester from the Rehabilitation Research and Training Center on Aging with Developmental Disabilities (RRTCADD), Department of Disability and Human Development at the University of Illinois at Chicago. The RRTCADD is funded by Grant # H133B080009 from the US Department of Education, Office of Special Education and Rehabilitative Services, National Institute on Disability and Rehabilitation Research. Ethical approval: This study was approved by the University of Rochester Research Subjects Review Board and the protocols used by NHANES and NHIS were approved by the National Center for Health Statistics (NCHS) Institutional Review Board. Conflict of Interest: none. References 1. Rosenbaum P, Paneth N, Leviton A, et al.   A report: the definition and classification of cerebral palsy April 2006. Dev Med Child Neurol Suppl  2007; 109( Suppl 109): 8– 14. Google Scholar PubMed  2. Turk MA. 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Family PracticeOxford University Press

Published: Apr 27, 2018

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