Maintaining mobility in late life. II. Smoking, alcohol consumption, physical activity, and body mass index

Nondisease factors affected trajectories of disability in a prospective study

OBJECTIVE

To examine nondisease factors, including sociodemographic variables, health behaviors and psychosocial factors as determinants of trajectories of disability.

STUDY DESIGN AND SETTING

We used a classification of 10 trajectories of disability based on a multiround prospective study design; nine trajectories grouped survivors with a similar level and time course of disability, one included all deaths. Multinomial logistic regression was used to assess associations between these trajectories and a wide range of nondisease factors.

RESULTS

Correcting for age, sex, and four chronic diseases, we found that sociodemographic factors (education and income), health behaviors (leisure-time physical activity and BMI), and psychosocial factors (locus of control, neuroticism, and active problem focusing) were significantly associated with the trajectories of disability. Moreover, our results pointed to factors associated with disability trajectories that were characterized by sudden increase (external locus of control and, to a lesser extent, BMI), strong fluctuations (neuroticism, BMI, external locus of control), or high severity (leisure-time physical inactivity) of disability.

CONCLUSION

A wide range of nondisease factors is associated with the trajectories of disability. Preventing obesity, developing a more internal locus of control, and increasing physical activity could contribute to preventing trajectories characterized by rapid decline, large fluctuations or severe disability. Understanding the role of these factors should receive high priority.

Prospective study of physical activity and physical function in early old age

BACKGROUND

In the elderly, higher levels of physical function have consistently been associated with higher levels of physical activity. In this study, we test the hypothesis that physical activity earlier in the life course preserves high physical function over an extended period of time, before the onset of major age-related declines in physical function.

METHODS

A cohort study with an average of 8.8 years of follow-up (1991-1993 to 2001). Logistic regression analyses were conducted adjusting for long-standing illness, baseline physical function, smoking, body mass index, and employment grade. Participants were 6398 London-based civil servants aged 39 to 63 years at baseline, 90% of whom were working. The main outcome measure was physical function measured by the Short Form (SF-36) General Health Survey.

RESULTS

Relatively fit and healthy, mainly working, middle-aged men and women who were physically active at recommended levels, were more likely to report high physical function at follow-up, compared to their sedentary counterparts (odds ratio 1.63, 95% confidence interval 1.32-2.00). The association between initial level of physical activity and high physical function at follow-up remained after adjustment for baseline level of physical function and the presence of long-standing illness.

CONCLUSIONS

Participation in a physically active lifestyle during mid-life appears to be critical to the maintenance of high physical function in those who are fit and well enough to work and do or do not report any long-standing illness.

[Physical activity and quality of life in older adults in Spain]

BACKGROUND AND OBJECTIVE

This study examined the relationship between leisure-time physical activity (LTPA) and health-related quality of life (HRQL) in the older adult population of Spain.

SUBJECTS AND METHOD

Household cross-sectional survey on 3,066 subjects representatives of the non-institutionalized Spanish population aged 60 years and over. Data on LTPA was obtained with a structured questionnaire and HRQL was measured with the SF-36 instrument. Analyses were done through linear regression, where the dependent variable was each of the eight scales of the SF-36 and the main independent variable was LTPA. Analyses were adjusted for sociodemographic and social network variables, health habits, health services use, and chronic diseases.

RESULTS

A total of 42.7% subjects had a sedentary activity, 54.2% light LTPA and 3% moderate/intense LTPA. As compared with sedentary activity, light LTPA was associated with a higher score in all SF-36 scales, except for the physical role and emotional role, among men and women. For subjects with light LTPA the increase in score was over 3 points in most SF-scales, which is usually considered as a clinically relevant change in HRQL. Results did not vary materially by age, level of education, obesity or chronic disease. The higher LTPA, the better HRQL (p for linear trend < 0.05 in most scales of the SF-36 questionnaire).

CONCLUSIONS

Light LTPA is associated with better HRQL than sedentary activity. Because this association did not change with age, level of education, obesity or chronic disease, it is suggested that most older adults could improve their HRQL with, at least, a light LTPA.

Functional-task exercise versus resistance strength exercise to improve daily function in older women: a randomized, controlled trial

OBJECTIVES

To determine whether a functional-task exercise program and a resistance exercise program have different effects on the ability of community-living older people to perform daily tasks.

DESIGN

A randomized, controlled, single-blind trial.

SETTING

Community leisure center in Utrecht, the Netherlands.

PARTICIPANTS

Ninety-eight healthy women aged 70 and older were randomly assigned to the functional-task exercise program (function group, n=33), a resistance exercise program (resistance group, n=34), or a control group (n=31). Participants attended exercise classes three times a week for 12 weeks.

MEASUREMENTS

Functional task performance (Assessment of Daily Activity Performance (ADAP)), isometric knee extensor strength (IKES), handgrip strength, isometric elbow flexor strength (IEFS), and leg extension power were measured at baseline, at the end of training (at 3 months), and 6 months after the end of training (at 9 months).

RESULTS

The ADAP total score of the function group (mean change 6.8, 95% confidence interval (CI)=5.2-8.4) increased significantly more than that of the resistance group (3.2, 95% CI=1.3-5.0; P=.007) or the control group (0.3, 95% CI=-1.3-1.9; P<.001). Moreover, the ADAP total score of the resistance group did not change significantly compared with that of the control group. In contrast, IKES and IEFS increased significantly in the resistance group (12.5%, 95% CI=3.8-21.3 and 8.6%, 95% CI=3.1-14.1, respectively) compared with the function group (-2.1%, 95% CI=-5.4-1.3; P=.003 and 0.3%, 95% CI=-3.6-4.2; P=.03, respectively) and the control group (-2.7%, 95% CI=-8.6-3.2, P=.003 and 0.6%, 95% CI=-3.4-4.6; P=.04, respectively). Six months after the end of training, the increase in ADAP scores was sustained in the function group (P=.002).

CONCLUSION

Functional-task exercises are more effective than resistance exercises at improving functional task performance in healthy elderly women and may have an important role in helping them maintain an independent lifestyle.

Associations of functional ability with health-related behavior and body mass index among the elderly

The main purpose of this study was to determine whether functional ability among the elderly associates with body mass index (BMI) and health-related behavior. The secondary aim was to examine whether health behavior and BMI can be seen as mechanisms explaining sociodemographic disparities in functional ability. Cross-sectional biennial surveys from 1985 to 2001 were used to study 11,793 Finnish people aged 65-79 years. Associations of activities of daily living (ADL) with BMI, health behaviors (smoking, alcohol consumption, diet, physical activity), time period, previous occupation, marital status and certain diseases were tested using an ordinal regression model. Current and ex-smoking, heavy and non-alcohol use, unhealthy diet, physical inactivity and obesity were associated with inferior ADL. Alcohol consumption among men showed a U-shaped relation to functional ability. Most of the differences in ADL by occupation and marital status vanished after adjustment of multiple factors. The results showed clear associations of ADL with health-related behaviors and BMI when adjusted for multiple factors. The findings suggesting a U-shaped relation between ADL and alcohol consumption among men and the association between diet and ADL add to our previous knowledge of factors related to functional ability.

[The Bambui Health and Aging Study (BHAS): a population-based cohort study of prevalence and factors associated with the needs of caregivers for the elderly]

The objective of this study was to determine the prevalence and factors associated with the needs of caregivers for older adults living in the community. All residents (n = 1,742) of Bambuí, Minas Gerais State, Brazil (15,000 inhabitants) aged > or = 60 years were selected. Of these, 92% were interviewed and 86% were examined. The dependent variable "need for a caregiver" was defined as the inability to perform at least one of the basic activities of daily living and/or a Mini Mental score under 13. Some 23% of the elderly required caregivers. After adjustment for confounding, independent and positive associations with the need for a caregiver were found for: age, single marital status, history of alcohol abuse, hypertension, obesity, and use of > or = 2 prescription drugs. Independent and negative associations were found for: level of schooling, familiar income, living alone, total cholesterol > 240 mmHg, and having a private health plan. Those requiring caregivers presented evidence of worse socioeconomic and health status. The study provides evidence that care of the dependent elderly is a public health problem.

Incidence of loss of ability to walk 400 meters in a functionally limited older population

OBJECTIVES

To assess the incidence of and factors related to nondisabled but functionally limited older adults aged 75 to 85 years losing the ability to walk 400 m.

DESIGN

Observational study with average follow-up of 21 months.

SETTING

Community.

PARTICIPANTS

At baseline, 101 persons with objective signs of functional limitations and intact cognitive function agreed to participate in the study. Of these, 81 were able to walk 400 m at baseline, and 62 participated in the follow-up examination.

MEASUREMENTS

Mobility disability was defined as an inability to complete a 400-m walk test. At baseline, eligible participants (n=81) had the ability to walk 400 m, scored between 4 and 9 on the Short Physical Performance Battery (SPPB; range 0-12), and scored 18 or more on the Mini-Mental State Examination. Demographics, difficulty in daily activities, disease status, behavioral risk factors, and muscle strength were assessed at baseline and follow-up.

RESULTS

Of 62 persons at follow-up, 21 (33.9%) developed incident mobility disability. The strongest predictors of loss of mobility were the time to complete the 400-m walk at baseline (odds ratio (OR)=1.6 per 1-minute difference, 95% confidence interval (CI)=1.04-2.45), and decline in SPPB score over the follow-up (OR=1.4 per 1-point difference, 95% CI=1.01-1.92).

CONCLUSION

Older persons with functional limitations have a high rate of loss of ability to walk 400 m. The 400-m walk test is a highly relevant, discrete outcome that is an ideal target for testing preventive interventions in vulnerable older populations.

Functional tasks exercise versus resistance exercise to improve daily function in older women: a feasibility study

OBJECTIVE

To evaluate the feasibility of a new functional tasks exercise program, designed to improve functional performance of community-dwelling older women, by comparing it with a resistance exercise program.

DESIGN

A 12-week, randomized, single-blind pilot study.

SETTING

A community leisure center.

PARTICIPANTS

Twenty-four community-dwelling, medically stable women (mean age, 74.6+/-4.8 y) were randomized to the functional tasks exercises (function group) or the resistance exercises (resistance group). Three participants withdrew from the study.

INTERVENTIONS

Exercises were given 3 times weekly for 12 weeks. The functional tasks exercise program aimed to improve daily tasks in the domains first affected in older adults, whereas the resistance exercise program focused on strengthening the muscle groups that are important for functional performance.

MAIN OUTCOME MEASURES

Participant satisfaction with the exercises, Assessment of Daily Activity Performance (ADAP), and, as a secondary outcome, muscle strength and power.

RESULTS

Exercise adherence was 81% in the function group and 90% in the resistance group. Participants reported greater satisfaction with the resistance exercises than with the functional exercises. The ADAP total score improved with time (P =.001; mean change function group, 7.5 U; 95% confidence interval [CI], 2.1-12.8; resistance group, 2.8 U, 95% CI, -0.4 to 5.9), as did isometric knee extensor strength (P =.001; mean change function group, 6.4%; 95% CI, -1.6 to 14.5; resistance group, 14.4%; 95% CI, 6.4-22.2). Testing for differences in outcomes between the 2 groups showed no statistically significant differences.

CONCLUSIONS

The functional tasks exercise program is feasible and shows promise of being more effective for functional performance than a resistance exercise program. A randomized controlled trial with a larger sample size is needed to test the difference between the 2 programs.

Risk factors for foot fracture among individuals aged 45 years and older

A case-control study undertaken among members of five Northern California Kaiser Permanente medical centers sought to identify risk factors for foot fractures among persons aged 45 years and older. Foot fracture cases (n=920) and frequency matched controls (n=2366) were interviewed between October 1996 and May 2001 using a standardized questionnaire. Foot fractures occurred most often while walking or climbing stairs. While 60% of foot fractures resulted from falls, 20% were attributed to other causes, such as hitting the foot or tripping on sidewalks and curbs. Having a self-reported history of physician-diagnosed diabetes [adjusted odds ratio (OR)=1.45, 95% confidence interval (CI)=1.10-1.91] or cataracts (OR=1.40, 95% CI=1.07-1.83), having a self-reported foot problem (OR=1.38, 95% CI=1.06-1.78 for two or more foot problem versus no foot problems), having difficulty walking in minimum light (OR=1.86, 95% CI=1.14-3.05) and having had a prior fracture (OR=1.20, 95% CI=1.05-1.37) were associated with increased risk. Putative protective factors for osteoporotic fractures, such as menopausal hormone therapy use, thiazide or water pill use, high calcium intake, and high body mass index were not associated with foot fracture risk. These findings suggest that risk factors for foot fractures among older people differ in part from risk factors for other fracture sites generally considered to be osteoporotic, such as the hip, vertebrae, and forearm.

The impact of socio-economic factors on functional status decline among community-dwelling older adults in China

The purpose of this paper is to examine the impact of baseline socio-economic factors on functional status decline over a period of 3 years among a sample of Chinese older men and women, using the China Health and Nutrition Surveys of 1997 and 2000. In addition, the study tries to determine whether risk differentials by these socio-economic factors can be explained by other demographic, health-related and nutritional risk factors. The eligible study population was defined as women and men aged 55 years and over who at baseline were free from any form of disablement in activities of daily living (ADLs) or instrumental activities of daily living (IADL) tasks. Among subjects with complete data at followed-up (N = 976), the overall incidence proportions of any functional status decline, IADL only and ADL declines were 25.8%, 18.9% and 6.9%, respectively. Our study found that education is strongly and inversely associated with incidence of combined functional status decline and IADL only but not with the onset of ADL disability. Similarly, household income per capita was inversely associated with functional status decline and IADL disability incidence, with a clear dose-response relationship, even after adjustment for age and gender. However, multivariate analysis demonstrated that the latter association was highly confounded by other demographic factors, especially urban-rural area of residence. Using a combined measure of socio-economic status that includes years of education and household income per capita, the age and gender-adjusted odds ratio for functional status decline and belonging to lower SES class as compared to middle, upper middle and upper classes was 3.82 (95% CI: 2.15, 6.77) and 2.77 (95% CI: 1.52, 5.03) after further adjustment for urban-rural area of residence and living arrangements. Hence, there are wide socio-economic disparities in the functional health of older adults in China, although such disparities are more seen for IADL decline and are almost exclusively attributed to differentials in educational attainment. Finally, nutritional and health-related risk factors do not seem to act as intermediate factors in this association and hence further research should try to uncover other mechanisms by which SES affects changes in functional health among older adults in China.

Effects of physical activity and body composition on functional limitation in the elderly: application of the marginal structural model

BACKGROUND

Study of the influence of physical activity and body composition in the context of the disablement process requires analytic techniques that can address time-dependent confounding related to exposures for the occurrence of functional limitation and disability.

METHODS

We applied logistic marginal structural models to explore causal relationships between leisure time physical activity and a measure of relative muscle mass (the lean:fat mass ratio) and self-reported functional limitation. Subjects (n = 1655) were members of a population-based cohort recruited in Sonoma, California, in 1993-1994 (median age 70 years); they were surveyed 3 times over 6.5 years.

RESULTS

Based on the marginal structural model, the causal odds ratio for functional limitation with a 0.5-unit increment in relative muscle mass was 0.56 in women (95% CI = 0.46-0.67). This reduction in odds was not altered by adjustment for baseline covariates. The corresponding causal odds ratio in men was 0.77 (0.65-0.92). This also was not influenced by baseline covariates or levels of physical activity. There was evidence for an independent causal effect of increased levels of physical activity on reduction of odds of functional limitation for men but not for women. Obese women experienced no protective effect of increased lean-to-fat mass. Normal-weight women experienced a benefit with increasing levels of physical activity.

CONCLUSIONS

Marginal structural models provide a means to address time-dependent confounding, which can occur in longitudinal studies. These analyses indicate that leisure time physical activity exerts its beneficial effects through reductions in fat mass relative to lean body mass.

Relationship between body mass index and different domains of disability in older persons: the 3C study

OBJECTIVE

To study the relationships between body mass index (BMI) and different domains of disability in elderly subjects from the French 3C study.

SETTING

Three cities in France: Bordeaux (South-West), Dijon (North-East) and Montpellier (South-East).

DESIGN

Cross-sectional study.

SUBJECTS

A sample of 8966 elderly community dwellers (age: 65-101 y).

MEASUREMENTS

MAIN OUTCOME MEASURES

BMI, continence, basic and Instrumental Activities of Daily Living (ADL and IADL) and mobility. Adjustment variables: age, educational level, lifestyle, cognitive functioning, smoking and drinking history, depression, dyspnea, diabetes and indicator of cardiovascular disease.

RESULTS

Obesity (BMI> or =30 kg/m2) was significantly associated with disability in each domain for women. The relationship tended to be linear for ADL and for continence; whereas for IADL, underweight women (BMI <21 kg/m2) were also at higher risk of disability. In men, relationships were weaker since BMI was only associated with mobility restriction, with a higher risk for both underweight and obese subjects.

CONCLUSION

These results are in favor of a strong association between obesity and the three domains of disability and incontinence. Weaker relationships between underweight and disability were observed. Results suggest that maintaining a BMI in the healthy range could contribute to independence in activities of daily living.

The relationship among physical activity, obesity, and physical function in community-dwelling older women

BACKGROUND

The relationship between obesity and physical function is not well understood. Physical activity may be a key factor impacting on the relationship between obesity and physical function.

METHODS

Subjects included 171 community-dwelling women (mean age = 74.3, SD = 4.3) participating in a 14-year follow-up study to a walking intervention trial. Measures of obesity [body mass index (BMI)] and physical activity (Modified Paffenbarger Questionnaire) were collected in 1982, 1985, 1995, and 1999. Physical function was assessed in 1999 using the Functional Status Questionnaire (FSQ) and gait speed.

RESULTS

Measures of obesity from 1982 to 1995 and measures of physical activity from 1982 to 1995 were related to physical function in 1999. However, hierarchical regression analysis to predict physical function in 1999 controlling for the presence of chronic conditions indicated that physical activity from 1982 to 1995, and not obesity from 1982 to 1995, was an independent predictor of physical function (FSQ: adjusted R2 = 0.09, F = 4.68, P < 0.001; gait speed: adjusted R2 = 18.0, F = 9.41, P < 0.0001.

CONCLUSION

Physical activity appears to be as important if not more important than body weight in predicting future physical function.

Mobility limitations 1974-1991: period changes explaining improvement in the population

The proportion of people with mobility limitations (difficulties with running, walking and stairs) decreased between 1968 and 1991 in the Swedish population aged 18-75. The distribution of predictors of late life morbidity, e.g., social class, health behaviour and childhood conditions, also changed during this period. This study explored whether the changes in these predictors over time were related to the decrease in the proportion of the population with mobility limitations. In two nationally representative interview samples (n=4468) from 1974 and 1991 of persons aged 45-71 the odds for limitations were cross-sectionally compared in ordered logistic regression models. In addition, predictors for the mobility outcome in 1974 were collected from an earlier 1968 survey and predictors for the 1991 outcome were collected from 1981. In 1974 the odds for limitations in the population was 50% higher than in 1991. Had the population composition regarding social class and housewives in 1991 been identical to 1974, the odds for limitations would have been similar in 1974 and 1991. Period improvement in social classes with poorer mobility also contributed to the overall period improvement. Health behaviours were examined as possible mediating factors. The increase of physically active people between 1968 and 1974 was related to the period improvement in mobility between 1974 and 1991. Smoking showed an increased association with mobility limitations during the period, indicating that mobility improvement would have been greater if everyone had been a non-smoker. Results indicate how sensitive disability rates may be for cohort or period effects.

A co-twin control study of physical function in elderly African America women

OBJECTIVE

This study investigated variables associated with physical functioning limitations among elderly African American women, controlling for genetics and common family environment.

METHOD

Activities of daily living limitations (ADL) and instrumental activities of daily living limitations (IADL) are examined in 180 pairs of African American elderly twins using a co-twin control design. The association of chronic disease, other physical problems, lifestyle, and demographic factors with both measures are investigated.

RESULTS

Arthritis, hypertension, and more than 1 chronic disease are associated with ADL limitations and arthritis; diabetes, heart attack, and more than 1 chronic disease are associated with IADL limitations in univariate analyses. In multivariate analyses, a different set of additional variables is associated with the two measures.

DISCUSSION

Among elderly African American women, physical functioning limitations are influenced by the presence of chronic diseases, other physical problems, lifestyle, and demographics. These associations are not due to genetics or common family environment effects.

Prevalence and correlates of overweight and obesity among older adults: findings from the Canadian National Population Health Survey

BACKGROUND

The prevalence of obesity among elderly persons in industrialized countries ranges from 15% to 20%. Little is known about variations of overweight within subgroups of the elderly population. This study examined the factors associated with overweight and obesity among older men and women.

METHODS

Data for 12,823 community-dwelling persons aged 65 and older from the 1996-1997 Canadian National Population Health Survey were examined. Predictors of overweight (body mass index [BMI] = 25.0-29.9 kg/m2) and obesity (BMI = >30 kg/m2) relative to normal weight (BMI = 20.0-24.9 kg/m2) were examined using logistic regression analyses. Analyses were stratified by gender. The predictor variables included age, education, marital status, place of birth, region, smoking status, alcohol use, chronic conditions, physical activity, functional limitations, self-rated health, social support, and psychological distress.

RESULTS

Overall, 39% and 13% of Canadian older adults were classified as overweight and obese, respectively. Some of the risk factors for overweight were male gender, low education, being married, Canadian born, residence in the Atlantic provinces, no use of alcohol, comorbidity, physical inactivity, and limited functional status. Risk factors for obesity were similar to those for overweight except for being unmarried; American, European, and Australian born; lower and higher levels of alcohol use; poor self-rated health; and psychological distress.

CONCLUSIONS

The results could lead to more effective weight-control interventions that are designed to promote increased physical activity and healthy eating habits among obese older individuals.

The effect of advice by health care professionals on increasing physical activity of older people

The aim of this study was to investigate whether advice by health care professionals is associated with increased exercise activity in older people. As part of the Evergreen follow-up study, self-report data on exercise related advice were collected in 1996 and physical activity in 1988 and 1996 among 611 non-institutional people initially aged 65-84 years. Logistic regression analyses were used to study the association of recollection of having received exercise counseling with increased activity. Of all the subjects, 92% reported having been in contact with health care professionals during the follow-up period, and 58% of them recalled having been advised to exercise. Those men and women who recalled having received advice, started to participate in supervised exercise classes 5-6 times more often than those who did not recall being advised. The odds ratio (95% confidence interval) in men was 6.27 (1.19-32.9), and in women 5.27 (1.97-14.1). For calisthenics at home, the corresponding figure was 12.5 (3.52-44.4) in men. We concluded that initiating new physical activities in old age is strongly connected to encouragement to exercise by health care professionals. Health care professionals should be supported to promote exercise among older patients.

Examining the disablement process among older Mexican American adults

The Disablement Process model (Verbrugge and Jette, Social Science & Medicine 38 (1994) 1) describes a pathway leading from pathology to impairment to functional limitations, and, ultimately to disability. Components of this model have been examined among older White adults; however, very little research has examined the disablement process among older adults of other ethnic groups. Our goal in this research is to evaluate the Disablement Process model using Activities of Daily Living (ADL) disability as the outcome among a representative group of older Mexican American adults in the Southwestern United States. Respondents are from two waves of the Hispanic Established Populations Epidemiologic Study of the Elderly (EPESE) (n=2439). Structural equation models (LISREL 8.30) are utilized to examine the Disablement Process model. We also investigate aspects of the original model that have potentially important effects on the process of becoming disabled, such as cognitive impairment and perceived emotional support. Findings from structural equation models suggest that the main pathway from pathology to ADL disability is through functional limitations among older Mexican Americans. Risk factors, especially age and gender, have significant indirect effects on ADL disability. The main pathway in the Disablement Process model receives preliminary support among older Mexican Americans. We discuss implications of this model for future research.

Effects of an exercise intervention on immunologic parameters in frail elderly nursing home residents

BACKGROUND

Aging is associated with decline in both cell-mediated and humoral immunity and may contribute to increased incidence and severity of infections in frail elderly. Exercise, depending on intensity, has significant effects on the immune system. We conducted a randomized, controlled clinical trial of a 32-week functionally oriented exercise program in frail elderly living in nursing homes and determined whether the exercise intervention was associated with a change in immune parameters in this frail elderly nursing home population.

METHODS

Nursing home residents were randomly assigned to an intervention (n = 94) and control group (n = 96). The intervention consisted of a functionally oriented endurance and resistance exercise training that was provided every 2 hours from 8:00 AM to 4:00 PM for 5 days a week for 8 months. Lymphocyte subpopulations, including activation markers (CD28, CD25, HLA-DR), in vitro proliferation, and soluble products of cytokine activity (neopterin and sTNF-RII) in serum were measured by taking blood samples at baseline and after 8 weeks and 32 weeks of the intervention.

RESULTS

Exercise training did not induce changes in lymphocyte subpopulations, activation markers (CD28, CD25, HLA-DR), in vitro proliferation, and soluble products of cytokine activity (neopterin and sTNF-RII) in serum.

CONCLUSIONS

A 32-week exercise intervention did not bring about beneficial or detrimental effects on immune parameters in the frail elderly nursing home population and may explain why the intervention was not associated with a change in the incidence of infections in the intervention group compared with the control group.

Is there a relationship between excessive drinking and functional impairment in older persons?

OBJECTIVES

To investigate the relationship between (1) two thresholds of excessive alcohol drinking, (2) binge drinking, and (3) impairments in functional status in older drinkers.

DESIGN

Cross-sectional study.

SETTING

Ten internal medicine practices affiliated with an academic medical center.

PARTICIPANTS

One hundred sixty-one persons aged 60 and older who reported drinking one or more drinks in the previous 3 months.

MEASUREMENTS

Two commonly used thresholds of excessive drinking: (1) eight to 14 drinks per week for women and men (lower threshold) and (2) more than 14 drinks per week for women and men (higher threshold); a measure of binge drinking (> or =3 drinks per occasion for women or > or =4 drinks per occasion for men); and self-reported instrumental activities of daily living (IADLs) and advanced activities of daily living (AADLs).

RESULTS

Compared with older persons consuming seven or fewer drinks per week, those exceeding the higher threshold of excessive drinking were more likely to have impairments in IADLs (adjusted odds ratio (AOR) = 8.4) and, to a lesser extent, AADLs (AOR = 3.7); those exceeding the lower threshold were more likely to have impairments in IADLs (AOR 5 6.0) but not in AADLs (AOR = 1.7). Binge drinkers were also more likely to have impairments in IADLs (AOR = 3.0) but not in AADLs (AOR = 1.5).

CONCLUSIONS

In this group of older men and women, drinking more than seven drinks per week was associated with impairments in IADLs and, to a lesser extent, AADLs. Drinking more than three drinks per occasion was associated with impairments in IADLs.

Improved functional status in 16 years of follow up of middle aged and elderly men and women in north eastern Finland

STUDY OBJECTIVE

To investigate age, period, and cohort effects on functional status.

DESIGN

A prospective cohort study with measurements in 1981, 1990, and 1996.

SETTING

Three municipalities in north east Finland.

PARTICIPANTS

A regionally representative sample of 19 to 63 year old men and women was drawn from the census data in 1979, of which 758 men and 1033 women initially aged 39-63 years entered the study in 1980 and completed the follow up in 1996 (90.9% of the alive cohort).

MEASUREMENTS AND MAIN RESULTS

Functional status was determined based on self estimated disabilities (difficulties or not able) to walk 2 km, climb several flights of stairs, and run 100 m. The age adjusted odds of disability in stair climbing and running were lower among the men and the women in 1990 and 1996 than among the men and the women in 1981. There was a declining trend in the odds of disability with succeeding birth cohorts among both the men (odds ratios (OR) 0.79 and 95% confidence intervals (CI) 0.70 to 0.88 for stair climbing and OR 0.88 and 95% CI 0.78 to 0.98 for running) and the women (OR 0.85 and 95% CI 0.77 to 0.93 for stair climbing and OR 0.85 and 95% CI 0.76 to 0.94 for running). No statistically significant differences in walking disability were found between the study periods or the study cohorts.

CONCLUSIONS

The findings depict an improved time trend in functional status in the study population, with implications for future health and social care planning.

Physical activity as a determinant of change in mobility performance: the Longitudinal Aging Study Amsterdam

OBJECTIVES

This study examined the association of (change in) physical activity and decline in mobility performance in older men and women.

DESIGN

A 3-year prospective study using data of the Longitudinal Aging Study.

SETTING

Netherlands.

PARTICIPANTS

Two thousand one hundred nine men and women aged 55 to 85.

MEASUREMENTS

Total physical activity (expressed as hours per day and kilocalories per day) and sports participation were measured using a validated, interviewer-administered questionnaire. Mobility performance was assessed using two timed tests: 6-meter walk and repeated chair stands.

RESULTS

Mobility performance declined for 45.6% of the sample. At baseline, the mean time +/- standard deviation spent on total physical activity was 3.0 +/- 2.1 h/d or 719 +/- 543 kcal/d, and 56.6% of the sample participated in sports. Sports participation and a higher level of total physical activity, walking, or household activity were associated with a smaller mobility decline. After 3 years, total physical activity declined, and only 53.4% of those reporting sports at baseline continued doing so. Continuation of physical activity over time was associated with the smallest decline in mobility. The observed associations were similar for those with and without chronic disease (P> 0.3). The conclusions did not change after adjustment for potential confounders, including demographic and lifestyle variables, depression, and cognitive status.

CONCLUSIONS

Physical activity, and especially a regularly active lifestyle, may slow the decline in mobility performance. A beneficial effect was observed for sports and nonsports activities, independent of the presence of chronic disease.

Percentage of body fat and body mass index are associated with mobility limitations in people aged 70 and older from NHANES III

OBJECTIVES

To assess the association between functional limitations and body composition indices, including percentage of body fat, muscle mass, and body mass index (BMI).

DESIGN

A cross-sectional, population-representative sample.

SETTING

All noninstitutionalized people living in the United States (National Health and Nutrition Examination Survey). Data were collected between 1988 and 1994.

PARTICIPANTS

One thousand five hundred twenty-six women and 1,391 men aged 70 and older.

MEASUREMENTS

Independent variables included BMI, muscle mass, and percentage of body fat; the latter two were assessed using predictive equations. The dependent variable, functional limitations, was defined as difficulty in performing at least three of five functional living tasks, such as carrying a 10-pound bag of groceries.

RESULTS

Women in the highest quintile for percentage of body fat and women with a BMI of 30 or greater were two times more likely to report functional limitations than women in the comparison groups. Similar, but weaker, relationships were found among men; men in the highest quintile for body fat and men with a BMI of 35 or greater were 1.5 times more likely to report limitations. Low muscle mass (sarcopenia) and sarcopenia in combination with high percentage of body fat (sarcopenic obesity) were not associated with a greater likelihood of reporting functional limitations.

CONCLUSIONS

Prevention of excessive accumulation of body fat and maintenance of a BMI in the normal range may reduce the likelihood of functional limitations in old age.

Discriminating Characteristics of Community-Dwelling Elderly at High and Low Risk for Frailty

The study’s objective was to examine the health status, physical activity behaviors, and performance-based functional abilities of individuals classified as being at high or low risk for frailty and to determine which of these characteristics discriminates between the 2 groups. Participants were 78 community-dwelling individuals with an average age of 74 years; 37 were categorized as being at high risk and 42 at low risk for frailty. Logistic-regression analysis indicated that individuals classified as being at high risk for frailty were more likely to have visited the doctor more than 3 times in the past year, experienced a cardiac event, taken more than 4 medications a day, and participated in little or no physical activity. High-risk individuals were more likely to have poor balance, difficulty with mobility, decreased range of motion, poor unimanual dexterity, and difficulty performing activities of daily living than were those classified as being at low risk for frailty.

Anthropometric indices predict physical function and mobility in older Australians: the Australian Longitudinal Study of Ageing

OBJECTIVE

To evaluate, in terms of function and mobility, the predictive value of commonly adopted anthropometric 'definitions' used in the nutritional assessment of older adults, in a cohort of older Australians.

DESIGN

Prospective cohort study - Australian Longitudinal Study of Ageing (ALSA).

SETTING

Adelaide, South Australia (1992-1994).

SUBJECTS

Data were analysed from 1272 non-institutionalised (685 males, 587 females) older adults > or =70 years old in South Australia. Seven 'definitions' commonly used in the anthropometric assessment of both under- and overnutrition (including four using body mass index (BMI), waist-to-hip ratio, waist circumference and percentage weight change) were evaluated at baseline, for their ability to predict functional and mobility limitation assessed (by self-report questionnaire) at two years follow-up. All questionnaires were administered and anthropometry performed by trained investigators. The associations between the definitions and decline in mobility and physical function were evaluated over two years using multiple logistic regression.

RESULTS

A BMI >85th percentile or >30 kg m-2 or a waist circumference of >102 cm in males and >88 cm in females increased risk of functional and mobility limitations. Over two years, a loss of 10% body weight significantly increased the risk of functional and mobility limitations.

CONCLUSION

Maintaining weight within older adults, irrespective of initial body weight, may be important in preventing functional and mobility limitations. Excessive weight is associated with an increased risk of limitation in function and mobility, both key components of health-related quality of life.

Predictors of functional change: a longitudinal study of nondemented people aged 65 and older

OBJECTIVES

To identify factors associated with functional change in an older population and investigate interactions among selected potential risk factors.

DESIGN

A population-based prospective cohort study.

SETTING

A random sample was selected from the Group Health Cooperative members in the Seattle area from 1994 to 1996 and followed biennially.

PARTICIPANTS

Two thousand five hundred eighty-one people aged 65 and older, cognitively intact at baseline.

MEASUREMENTS

Functional status was measured by activities of daily living, instrumental activities of daily living, and performance-based physical function testing.

RESULTS

The cohort status at the time of these analyses was: deceased, 391; withdrawn, 179; dementia, 152; and on study, 1,873. The mean follow-up time was 3.4 years. Using linear regressions with Generalized Estimating Equation, selected medical conditions (diabetes mellitus, hypertension, coronary heart disease, cerebrovascular disease (CVD), osteoporosis, arthritis, and cancer), low cognitive function, depression, and smoking were associated with worse functional outcomes. Exercise and moderate alcohol use were associated with better functional outcomes. Over the follow-up period, coronary heart disease, CVD, and depression were associated with increased rates of functional decline. Exercise and moderate alcohol consumption were associated with decreased rates of functional decline. Significant interactions were observed between exercise and coronary heart disease, moderate alcohol use and CVD, and cognition and CVD.

CONCLUSIONS

Our study has identified not only risk factors associated with functional decline but also the interactions among these factors. These observations, along with other published research, add to the growing understanding of the underlying process of functional change and could provide a basis to design effective strategies to delay functional decline.

The health-related effects of alcohol use in older persons: a systematic review

Increased alcohol consumption is associated with substantial morbidity and mortality in young and middle-aged adult populations, but its effects on the health of older adults have received less attention. The objective of the study was to review published studies that assessed the effects of alcohol on falls or fall injuries, functional impairment, cognitive impairment, and all-cause mortality among older adults. MEDLINE database and bibliographies of selected citations were searched for English language studies published between 1966 and 1998 that examined the relationship between alcohol and one or more of the above outcomes. Also a study was analyzed if it included participants 60 years of age or older, or a broader age range of participants and reported results for older subgroups, or predominantly older participants as evidenced by a mean age of 65 years of age or above. Information on studies' sample sizes, exposure and outcome measures, and risk estimates were extracted, and articles were evaluated for methodologic quality using predetermined criteria. Eighty-four studies were identified that examined 91 potential exposure-outcome associations including falls or fall injuries (n = 26); functional impairment (n = 13); cognitive impairment (n = 32); and all-cause mortality (n = 20). The percentage of studies demonstrating harm, no association, or benefit by outcome included falls (15% vs. 81% vs. 4%); functional disability (38% vs. 46% vs. 16%); cognitive impairment (31% vs. 66% vs. 3%); and all-cause mortality (15% vs. 65% vs. 20%). Studies (n = 84) inconsistently adhered to methodologic standards. Although 90% provided eligibility criteria; 61% cited participation rates; and 73% described the methods used to measure alcohol exposure; only 44% adjusted for potentially important confounding factors; and 26% distinguished former drinkers from nondrinkers. Of the cohort studies (n = 47), 30% assessed for change in participants' exposure status over time, and 17% determined whether losses to follow-up varied by exposure status. The magnitude of risk posed by alcohol use for falls or fall injuries, functional disability, cognitive impairment, and all-cause mortality among older adults remains uncertain. Prospective studies are needed to better define the health-related effects of alcohol use in older populations.

Common chronic diseases and general impairments as determinants of walking disability in the oldest-old population

OBJECTIVES

Walking disability affects older people's autonomy and well-being. We investigated the relative effect of common chronic diseases and general impairments on walking disability in the general oldest-old population.

DESIGN

Population-based cohort study.

SETTING

Leiden 85-plus Study, the Netherlands.

PARTICIPANTS

Five hundred ninety-nine persons aged 85, response rate 87%.

MEASUREMENTS

Walking disability was assessed using a 6-meter walking test. Persons with a walking time below the 25th percentile and those who were physically unable to perform the walking test were categorized as having a walking disability. Information on common chronic diseases was obtained from records of subjects' general practitioners and pharmacies. General impairments were assessed with functional tests and standardized questions during face-to-face interviews. We expressed the effect of common chronic diseases and general impairments as the population attributable risk (PAR), indicating how much disability can be prevented when the identified risk factor is eliminated from the population.

RESULTS

One hundred ninety-two persons (33%) had a walking disability. This disability was highly associated with poor mobility in daily life, recurrent falls, and poor well-being (all P <.001). Of the common chronic diseases, stroke, angina pectoris, diabetes mellitus, and hip fracture but not arthritis contributed most (PARs from 6% to 15%) to walking disability in the population at large. General impairments had higher prevalence rates and higher PARs than common chronic diseases. Cognitive impairment, depressive symptoms, and dizziness upon rising contributed most (PARs between 22 to 27%) to walking disability. In multivariate regression analyses of all common chronic diseases and general impairments, associations remained significant.

CONCLUSION

Within the general oldest-old population, general impairments contribute more substantially to walking disability than do common chronic diseases. The diagnosed diseases did not explain the impairments that led to walking disability. Especially in the oldest old, clinicians should focus not merely on common chronic diseases but particularly on general impairments as targets for diagnostic analysis and treatment to decrease walking disability.

Body mass index and physical function in older women

OBJECTIVE

We modified existing standardized measurement tools in the Physical Performance Test and tasks from the Frailty and Injuries: Cooperative Studies of Intervention Technique Study to evaluate physical function in older women. Our objectives were (1) to characterize physical function themes based on combinations of tasks (deriving factors or components) and (2) to quantify the correlation between derived factors and body mass index (BMI).

RESEARCH METHODS AND PROCEDURES

Nutrition risk screens from enrollees in a Medicare-managed risk program served as the sampling frame. To obtain adequate representation for a range of BMI, a random sample was obtained of 90 women from the following BMI strata: BMI, 22 to <27 kg/m(2); BMI, 27 to <30 kg/m(2); and BMI, > or =30 kg/m(2). Subjects were asked to perform a series of 18 functional tasks during a home visit.

RESULTS

The mean age was similar in the three BMI groups with an overall mean age of 71 +/- 4.9 years (SD). Factors characterized by lower-body function, upper-body function, coordination, and strength were responsible for 30%, 11%, 9%, and 9% of the variance in task scores, respectively. BMI, controlling for age, explained 5%, 14%, 3%, and 0% of the variation in these factors, respectively. Higher BMI is associated significantly with poorer upper- and lower-body function but is not associated significantly to strength or coordination.

DISCUSSION

Higher BMI seems to differentially impede specific aspects of physical function, especially upper-body function, and to a lesser extent, lower-body function. BMI does not seem to be associated with levels of coordination or strength. Better understanding of how BMI impacts physical function will aid in the design of interventions to promote independent living in elderly, obese women.

Peripheral arterial disease: epidemiology and drug therapy

Lower-extremity peripheral arterial disease (PAD) is common among older men and women, affecting 20%-30% of older men and women in general medicine practices. History and physical examination are insensitive measures of PAD. However, PAD can be noninvasively and reliably diagnosed in the office with the ankle-brachial index, a ratio of Doppler-recorded systolic pressures in the lower and upper extremities. An ankle-brachial index less than 0.90, consistent with PAD, is associated with increased risk of cardiovascular morbidity and mortality in addition to functional impairment. Drug therapy in PAD is directed at reducing the increased risk of cardiovascular events and improving walking impairment. Intensive atherosclerotic risk factor intervention and angiotensin-converting enzyme inhibitors are recommended for reducing cardiovascular event rates in persons with PAD. Components of an effective exercise intervention and drug therapy to reduce claudication-related walking impairment in PAD are also reviewed.

Lifestyle habits and compression of morbidity

BACKGROUND

There has been much debate regarding the degree to which healthy lifestyles can increase longevity and whether added years will be offset by increased morbidity at older ages. This study was designed to test the compression of morbidity hypothesis, proposing that healthy lifestyles can reduce and compress disability into a shorter period toward the end of life.

METHODS

Functional status in 418 deceased members of an aging cohort was observed between 1986 and 1998 in relationship to lifestyle-related risk factors, including cigarette smoking, physical inactivity, and under- or overweight. Three risk groups were created based on the number of these factors at study entry. Disability scores prior to death were modeled for each risk group to compare levels and rates of change, as well as to determine if and when acceleration in functional decline occurred.

RESULTS

The risk-factor-free group showed average disability scores near zero 10-12 years before death, rising slowly over time, without evidence of accelerated functional decline. In contrast, those with two or more factors maintained a greater level of disability throughout follow-up and experienced an increase in the rate of decline 1.5 years prior to death. For those at moderate risk, the rate of decline increased significantly only in the last 3 months of life. Other differences between groups provided no alternative explanations for the findings.

CONCLUSIONS

These results make a compelling argument for the reduction and postponement of disability with healthier lifestyles as proposed by the compression of morbidity hypothesis.

Identifying postmenopausal women at high risk of fracture in populations: a comparison of three strategies

OBJECTIVES

To describe the prevalence of risk factors for women at high risk of fracture in a population-based sample of postmenopausal women who were not using hormone replacement therapy (HRT), to demonstrate how the estimated prevalence of women at high risk of future fracture is affected by the different criteria used for classification, and to characterize the populations identified and missed by each of the criteria. A key study objective was to compare the proportion of postmenopausal women at high risk of fracture in a managed care population using several different definitions of who is at high risk.

DESIGN

The Osteoporosis Population-based Risk Assessment study, a randomized trial of three screening strategies.

SETTING

Conducted at Group Health Cooperative in western Washington state.

PARTICIPANTS

Women aged 60 to 79 who had not used HRT for at least 12 months were chosen at random.

MEASUREMENTS

In one of the trial arms, 428 women had their bone mineral density (BMD) measured at the hip and spine (L1-L4) using dual energy x-ray absorptiometry. Minimum t scores and z scores at all sites were used for classification. Risk factors for fractures were assessed at the time of the BMD scan.

RESULTS

Guidelines based on the Study of Osteoporotic Fractures classified 25.1% of the women as being at high risk of fracture, compared with 30.0% and 68.0% using World Health Organization (WHO) recommendations and National Osteoporosis Foundation guidelines, respectively. Classification based on low BMD alone (WHO) failed to include more than 50% of women who had already experienced a clinical fracture.

CONCLUSIONS

Prevalence of women at high risk of fracture not using HRT varies notably depending on the criteria used for identification. The criteria used to identify women to target for primary and secondary prevention of osteoporotic fractures has major implications for population-based prevention strategies.

Body-mass index and 4-year change in health-related quality of life

OBJECTIVE

To determine the effect of body-mass index (BMI) categories (a proxy for adiposity) on 4-year changes in health-related quality of life (HRQL) independent of baseline disease severity.

DESIGN

Secondary analyses of a prospective, longitudinal study.

PARTICIPANTS

Data on 7,895 adults ages 51 to 61 years who responded to the Health and Retirement Surveys in 1992, 1994, and 1996 were included.

RESULTS

Estimates of the effect of BMI on changes in HRQL were adjusted by disease severity. Each BMI category was associated with an increasing risk of decline in perceived health, with the highest risk in the higher categories. A BMI of between 30 and 35 was associated with a risk of decline in mobility.

CONCLUSIONS

The findings suggest a significant impact of BMI on changes in HRQL that is independent of disease severity and baseline HRQL.

Alcohol, drugs and much more in later life

Elderly adults are greater consumers of prescription and 'over the counter' medications than any other age group and polypharmacy, including the co-use of alcohol, is common in this group. Age related physiological changes which influence drug concentrations, metabolism, polypharmacy and interaction of other drugs with alcohol can negatively influence functional capacity, psychomotor ability, and cognition, including attention and memory, placing the older person at greater risk of accident, injury, isolation and ultimately institutionalisation. It is argued that DSM-IV criteria used to define "abuse" or "dependence" are of limited value to the majority of elderly 'problem' alcohol or drug users, with ICD-10 criteria that identify those who are experiencing 'a risk' of or where use "is actually" causing "early" harm, more appropriate. Impediments to psychiatrists and other medical practitioners identifying 'problem' alcohol and other drug use, and appropriate assessment and intervention procedures are briefly discussed. The potential for decreasing the incidence and severity of physical and psycho/social events following a reduction or cessation in problem alcohol or other drug use means that assessment and intervention should be one cornerstone of management practice for this often disenfranchised and vulnerable group.

The role of smoking and other modifiable lifestyle risk factors in maintaining and restoring lower body mobility in middle-aged and older Americans: results from the HRS and AHEAD. Health and Retirement Study. Asset and Health Dynamics Among the Oldest Old

OBJECTIVES

To analyze the effect of smoking, smoking cessation, and other modifiable risk factors on mobility in middle-aged and older Americans.

DESIGN

Panel study; secondary data analysis.

SETTING

United States (national sample).

PARTICIPANTS

The Health and Retirement Study (HRS) includes data on 12,652 Americans aged 50 to 61 in four waves (1992-1998). The Asset and Health Dynamics Among the Oldest Old (AHEAD) survey followed 8,124 community-dwelling people aged 70 years and older in three waves (1993-1998).

MEASUREMENTS

The relationships between the primary outcome measure, lower body mobility (ability to walk several blocks and walk up one flight of stairs without difficulty), and smoking, exercise (HRS only), body mass index (BMI), and alcohol use were estimated in bivariate and multivariate analyses.

RESULTS

Not smoking was strongly positively related to mobility, and the relative effects were similar in both panels. Among those with impaired mobility at baseline, not smoking was also strongly related to recovery. In the middle aged, there were consistent dose-response relationships between amount smoked and impaired mobility. Fifteen years after quitting, the risk of impaired mobility returned to that of never smokers. There was also a strong dose-response relationship between level of exercise and mobility. Inverted U-shaped relationships with mobility were observed for BMI and alcohol consumption.

CONCLUSIONS

The relationships between not smoking and lower body mobility in middle-aged and older Americans are strong and consistent. Interventions aimed at reducing smoking have the potential to preserve mobility and thereby prolong health and independence in later life.

A longitudinal study of the effects of tobacco smoking and other modifiable risk factors on ill health in middle-aged and old Americans: results from the Health and Retirement Study and Asset and Health Dynamics among the Oldest Old survey

BACKGROUND

While the effects of smoking and other modifiable risk factors on mortality and specific diseases are well established, their effects on ill health more generally are less known. Using two national, longitudinal surveys, the objective of this study was to analyze the effect of smoking and other modifiable risk factors on ill health, defined in a multidimensional fashion (i.e., disability, impaired mobility, health care utilization, and self-reported health).

METHODS

The analyses were based on the Health and Retirement Study (HRS) (12,652 persons 50-60 years old surveyed in 1992, 1994, 1996, and 1998) and the Asset and Health Dynamics among the Oldest Old survey (8,124 persons 60-70 years old surveyed in 1993, 1996, and 1998).

RESULTS

Smoking was strongly related to mortality and to ill health, with similar relative effects in the middle-aged and the elderly. There were consistent adverse dose-response relationships between smoking and ill health in the HRS. Persons who had quit smoking at least 15 years prior to the survey were no more likely than never smokers to experience ill health. A dose-response relationship was found between exercise and ill health. For body mass index and alcohol, there were U-shaped relationships with ill health.

CONCLUSIONS

Public health efforts designed to encourage smoking cessation should emphasize improvements in ill health in addition to decreased mortality.

Excess alcohol consumption and health outcomes: a 6-year follow-up of men over age 50 from the health and retirement study

AIMS

This study examined the association of problem drinking history and alcohol consumption with the onset of several health conditions and death over a 6-year follow-up period.

SETTING

We analyzed two waves of longitudinal data on men over 50 who participated in the Health and Retirement Study, a nationally representative sample of people aged 51-61 and their spouses living in the United States in 1992.

MEASUREMENTS

Five types of health outcomes--mortality, general health, functional status, cognitive status, and mental health--were examined. Drinking categories were based on average drinks per day (0, <1, 1-2, 3-4, 5+), with 5 + defined as 'very heavy drinking'. Problem drinking history was identified as 2+ affirmative responses to the CAGE questionnaire. We controlled for smoking and other factors at baseline.

FINDINGS

Over the 6-year follow-up period, very heavy drinking at baseline quadrupled the risk of developing functional impairments (OR: 4.21 95%, CI: 1.67, 10.61). A problem drinking history increased the onset of depression (OR: 1.67 95% CI: 1.02, 2.74), psychiatric problems (OR: 2.15 95% CI: 1.47, 3.13) and memory problems (OR: 1.71 95% CI: 1.14, 2.56). Heavy drinking among mature adults was not associated with increased incidence of other adverse health events (i.e. angina, cancer, congestive heart failure, diabetes, myocardial infraction, lung disease or stroke).

CONCLUSION

Very heavy drinking and a problem drinking history greatly increased rates of onset of functional impairments, psychiatric problems and memory loss in late middle age for men who had not experienced these impairments at their initial interview.

The ankle brachial index and change in lower extremity functioning over time: the Women's Health and Aging Study

OBJECTIVES

To define the association between baseline ankle brachial index (ABI) level and subsequent onset of severe disability.

DESIGN

Prospective cohort study.

SETTING

Baltimore community.

PARTICIPANTS

Eight hundred forty-seven disabled women aged 65 and older participating in the Women's Health and Aging Study.

MEASUREMENTS

At baseline, participants underwent measurement of ABI and lower extremity functioning. Measures of lower extremity functioning included patient's report of their ability to walk one-quarter of a mile, number of city blocks walked last week, number of stair flights climbed last week, and performance-based measures including walking speed over 4 meters, five repeated chair stands, and a summary performance score. Functioning was remeasured every 6 months for 3 years. Definitions of severe disability were developed a priori, and participants who met these definitions at baseline were excluded from subsequent analyses.

RESULTS

Participants with an ABI of less than 0.60 at baseline had significantly higher cumulative probabilities of developing severe disability than participants with a baseline ABI of 0.90 to 1.50 for walking-specific outcomes (ability to walk a quarter of a mile, number of city blocks walked last week, and walking velocity) but not for the remaining functional outcomes. In age-adjusted Cox proportional hazards analyses, hazard ratios for participants with a baseline ABI of less than 0.60 were 1.63 for becoming unable to walk a quarter of a mile (P = .044), 2.00 for developing severe disability in the number of blocks walked last week (P = .004), and 1.61 for developing severe disability in walking speed (P = .041), compared with participants with a baseline ABI of 0.90 to 1.50. Adjusting for age, race, baseline performance, and comorbidities, an ABI of less than 0.60 remained associated with becoming severely disabled in the number of blocks walked last week (hazard ratio = 1.97, P = .009) and nearly significantly associated with becoming unable to walk a quarter of a mile (hazard ratio = 1.54, P = .09). In fully adjusted random effects models, a baseline ABI of less than 0.60 was associated with significantly greater decline in walking speed per year (P = .019) and nearly significantly greater decline in number of blocks walked last week per year (P = .053) compared with a baseline ABI of 0.90 to 1.50.

CONCLUSION

In community-dwelling disabled older women, a low ABI is associated with a greater incidence of severe disability in walking-specific but not other lower extremity functional outcomes, compared with persons with a normal ABI over 3 years.

The effect of social support on exercise behavior in older adults

The purpose of this study was to test the relationship among social supports related to exercise (family, friends, and expert support), self-efficacy expectations, outcome expectations, and exercise behavior in a sample of older adults living in a continuing care retirement community. The sample included 74 older adults with a mean age of 85.6 +/- 5.5. Path analysis using Amos 4.0 was done. The model fit the data (chi-square = 4.6, df = 3, p = .21, normed fit index of .99, relative fit index of .98, and root mean square error of approximation of .08) and explained 53% of the variance in exercise behavior. Five of the seven hypothesized paths in the model were statistically significant. Friend support indirectly influenced exercise through self-efficacy and outcome expectations. This suggests interventions to improve exercise behavior in older adults should incorporate social supports to strengthen self-efficacy and outcome expectations related to exercise.

Motor performance in relation to age, anthropometric characteristics, and serum lipids in women

BACKGROUND

The relationships between motor performance and age, anthropometric characteristics, and serum lipids were studied in a population-based sample of women (N = 865).

METHODS

Motor performance was measured by a precise laboratory test, the Postural-Locomotion-Manual test, using an optoelectronic technique. Anthropometric measurements included body mass index (BMI) and waist-to-hip ratio. Blood samples were drawn for the measurement of total cholesterol, high-density lipoprotein (HDL) cholesterol, and triglyceride concentrations.

RESULTS

Motor performance deteriorated with age in a curvilinear way. High BMI, high waist-to-hip ratio, high triglycerides and low HDL cholesterol were all correlated to poor motor performance after adjustment for age, vascular disease, hypertension, diabetes, smoking, physical exercise, and some chronic diseases. Stepwise regression analyses showed that age, waist-to-hip ratio, triglycerides, HDL cholesterol, physical exercise, and vascular diseases were independent predictors of motor performance.

CONCLUSIONS

High age, high waist-to-hip ratio, high triglycerides, and low HDL cholesterol were associated with poor motor performance in women. Monitoring abdominal adiposity and serum lipids in clinical work might help us to identify people with early motor impairment and to prevent more severe mobility disability.

Persistent mobility deficit in the absence of deficits in activities of daily living: a risk factor for mortality

OBJECTIVES

To investigate the extent to which self-reported mobility deficit in the absence of impairment in activities of daily living (ADL) is associated with elevated mortality risk.

DESIGN

Prospective cohort study, with annual assessments of mobility and ADL status and ongoing monitoring of vital status.

SETTING

Population-based cohort drawn from Medicare enrollees in New York City.

PARTICIPANTS

One thousand two hundred ninety-eight older adults reporting functional status at baseline (1992-1994) and 2 years later.

MEASUREMENTS

Subjects reported mobility (e.g., walking, climbing stairs, and rising from a chair) and ADL (e.g., bathing, toilet use, dressing, grooming, and feeding) limitations. Two-year functional status trajectories were noted. We used two additional follow-up periods, at 2 and 4 years, to examine the likelihood that older people with mobility deficit may face an increased risk of death without first passing through a state of enduring ADL disability.

RESULTS

At 2 years, 12.7% had incident mobility deficit without ADL disability, and 21.3% were persistently disabled in mobility without ADL disability. Relative to subjects free of disability at baseline and follow-up, risk of mortality in the incident mobility deficit group was elevated at 2 and 4 years but did not achieve statistical significance. By contrast, for subjects with persistent mobility impairment who did not report ADL impairment, the mortality risk was significantly elevated both at 2 years (relative risk (RR) = 2.5; 95% confidence interval (CI) = 1.1-5.7)) and 4 years (RR = 2.9; 95% CI = 1.7-4.9)) of follow-up. Mortality was significantly elevated in this group in analyses restricted to respondents with no or only one comorbid condition.

CONCLUSION

Continuing, self-reported mobility impairment in the absence of ADL deficit is a risk factor for mortality. Older people with self-reported mobility deficit face an increased risk of mortality without first passing through enduring states of ADL disability.

Functional limitations in women at midlife: the role of health conditions, behavioral and environmental factors

This study examined risk factors for functional limitations in a community-based sample of 16,065 women from 5 ethnic groups, aged 40-55 years, enrolled in the Study of Women's Health Across the Nation. Almost 20% of this sample reported physical-functioning limitations. Functional limitations were associated with numerous disease conditions, including high blood pressure, diabetes, heart attack or angina, arthritis, osteoporosis, and cancer, and with several behavioral and environmental risk factors, including body mass index, difficulty paying for basics, and high levels of perceived stress. Consistent with findings in older women, this study shows that in addition to health conditions, potentially modifiable risk factors including high body mass index, difficulty paying for basics, and high levels of stress are associated with physical-functioning limitations of women at midlife.

Obesity in the elderly

In developed countries, there is a general increase in body weight and body mass index (BMI) with age, until approximately 60 years of age, when body weight and BMI begin to decline. The proportion of intra-abdominal fat, which is related to increased morbidity and mortality, progressively increases with age. There is also a progressive decline in energy intake and daily total energy expenditure (165 kcal/decade in men and 103 kcal/decade in women in developed countries), which is primarily due to a decrease in physical activity, and to a lesser extent, a decrease in basal metabolic rate. The decrease in physical activity is more pronounced in those with chronic disabilities and diseases. The BMI-mortality curves have been reported to move upward (greater overall mortality), become flatter (less effect of BMI on mortality), and in some cases shift to the right (minimum mortality occurs at a higher BMI), for a variety of possible reasons. Weight loss in the elderly has been reported to increase, decrease, or not alter mortality, but the studies are confounded by numerous methodological problems. It has been argued that there may be little benefit in encouraging weight loss in extreme old age (short life expectancy), especially when there are no obesity-related complications or biochemical risk factors and when strong resistance and distress arise from changes in lifelong habits of eating and exercise. In contrast, weight loss in the elderly can reduce morbidity from arthritis, diabetes and other conditions, reduce cardiovascular risk factors, and improve well-being. BMI also predicts morbidity in those without disease. Furthermore, increased physical activity in the elderly, which is an important component of weight management, can produce beneficial effects on muscle strength, endurance, and well-being.

Predictors of physical activity in community-dwelling elderly white women

OBJECTIVE

To describe patterns of physical activity and to determine factors associated with engaging in regular exercise, especially walking, in elderly white women.

DESIGN

Cross-sectional study of 9,442 independently living elderly white women aged 65 years and over participating in the Study of Osteoporotic Fractures.

MEASUREMENTS AND MAIN RESULTS

We studied the association between lifestyle habits, social factors, health status and self-reported physical activity (assessed by modified Paffenbarger scale) during the past twelve months. Walking was the most common form of exercise: 4,837 (51%) women reported doing so a mean of 12 (SD = 10) blocks per day, 3.9 (SD = 2.9) times per week. Other common activities were gardening (35%), swimming (16%), and bicycling (13%). Less than a third of women reported engaging in medium- or high-intensity exercise in the past year. In a multivariate age-adjusted analysis, factors independently (P < .01) associated with walking for exercise included greater than high school education (52% vs 48%), history of physical activity for exercise at ages 30 years (51% vs 46%) and 50 years (51% vs 45%), and stronger social network (51% vs 47%). Women who were current smokers, obese, or depressed were less likely to take walks for exercise. Marital status, self-reported arthritis, current estrogen use, and a history of falls in the past year were not independently associated with taking walks for exercise.

CONCLUSIONS

In this healthy cohort, walking for exercise is associated with other positive health behaviors. Given the mounting evidence about the health benefits of walking, and since many of these community dwelling women can and do walk for exercise, but rarely engage in other common prescribed physical activities, clinicians might best focus their efforts on encouraging walking.

Determinants of levels and changes of physical functioning in chronically ill persons: results from the GLOBE Study

STUDY OBJECTIVE

Declines in physical functioning are a common result of chronic illness, but relatively little is known about factors not directly related to severity of disease that influence the occurrence of disability among chronically ill persons. The aim of this study was to assess the effect of a large number of potential determinants (sociodemographic factors, health related behaviour, structural living conditions, and psychosocial factors).

DESIGN

Longitudinal study of levels and changes of physical functioning among persons suffering from four chronic diseases (asthma/chronic obstructive pulmonary disease (COPD), heart disease, diabetes, chronic low back pain). In 1991, persons suffering from one or more of these diseases were identified in a general population survey. Self reported disabilities, using a subset of the OECD disability indicator, were measured six times between 1991 and 1997. These data were analysed using generalised estimating equations, relating determinants measured in 1991 to disability between 1991 and 1997, and controlling for a number of potential confounders (age, gender, year of measurement, and type and severity of chronic disease).

SETTING

Region of Eindhoven (south eastern Netherlands).

PARTICIPANTS

1784 persons with asthma/COPD, heart disease, diabetes mellitus and/or low back pain.

MAIN RESULTS

In a "repeated prevalence" model, statistically significant (p<0.05) and strong associations were found between most of the determinants and the prevalence of disabilities. In a "longitudinal change" model, statistically significant (p<0.05) predictors of unfavourable changes in physical functioning were low income and excessive alcohol consumption, while we also found indications for effects of marital status, degree of urbanisation, smoking, and external locus of control.

CONCLUSIONS

Other factors than characteristics of the underlying disease have an important influence on levels and changes of physical functioning among chronically ill persons. Reduction of the prevalence of disabilities in the population not only depends on medical interventions, but may also require social interventions, health education, and psychological interventions among chronically ill persons.