Lower-extremity function in persons over the age of 70 years as a predictor of subsequent disability

Decreased mobility in the elderly: the exercise antidote

There is no age limit to the benefits of exercise. Regular activity, in fact, can often slow or reverse the decreased mobility that contributes to disease and disability in old age. Teasing out the relative contributions of disuse and genetically programmed decline can be difficult. However, clinical research demonstrates that for most elderly patients, including many who are frail or have concurrent illnesses, a program of aerobic, strength training, and flexibility exercise helps maintain mobility, improve quality of life, and prolong independence.

The role of change in physical performance in determining risk for dependence in activities of daily living among nondisabled community-living elderly persons

Among community-living elderly persons, a single assessment of physical performance is a powerful predictor of dependence in activities of daily living (ADLs). The aim of this study was to determine whether an assessment of change in physical performance provides useful prognostic information beyond that available from a single assessment. Among a large representative cohort of elderly persons, we evaluated the 586 participants who were ADL independent at both the baseline and the one year interviews. For each of the three timed tests, participants who had a large decline in physical performance were significantly more likely to develop ADL dependence at three years than those who improved or showed no change. After adjusting for 1-year scores, however, change in physical performance was no longer associated with ADL dependence. However, among the 775 participants who were ADL independent at the baseline interview, change in physical performance was significantly associated with the onset of ADL dependence at one year, even after adjusting for baseline performance. When determining risk for ADL dependence, an assessment of change in physical performance over one year does not provide useful prognostic information beyond that available from a single assessment. Nevertheless, change in physical performance is independently associated with concurrent ADL dependence and may be useful in predicting future disability if measured over shorter intervals.

Osteoarthritis: how to make exercise part of your treatment plan

The idea of exercising with swollen, painful joints and weakened muscles may seem counterintuitive. But increasingly research shows that the vicious cycle of immobility and dependence initiated by osteoarthritis can be interrupted by making exercise part of therapy. A well-designed program of aerobic and resistance training and whole-body flexibility and joint mobility exercise should join other interventions such as weight loss, medication, physical therapy, joint protection, and surgery to improve symptoms and reduce the impact of osteoarthritis on patients' lives.

Appendicular skeletal muscle mass: effects of age, gender, and ethnicity

This study tested the hypothesis that skeletal muscle mass is reduced in elderly women and men after adjustment first for stature and body weight. The hypothesis was evaluated by estimating appendicular skeletal muscle mass with dual-energy X-ray absorptiometry in a healthy adult cohort. A second purpose was to test the hypothesis that whole body 40K counting-derived total body potassium (TBK) is a reliable indirect measure of skeletal muscle mass. The independent effects on both appendicular skeletal muscle and TBK of gender (n = 148 women and 136 men) and ethnicity (n = 152 African-Americans and 132 Caucasians) were also explored. Main findings were 1) for both appendicular skeletal muscle mass (total, leg, and arm) and TBK, age was an independent determinant after adjustment first by stepwise multiple regression for stature and weight (multiple regression model r2 = approximately 0.60); absolute decrease with greater age in men was almost double that in women; significantly larger absolute amounts were observed in men and African-Americans after adjustment first for stature, weight, and age; and >80% of within-gender or -ethnic group between-individual component variation was explained by stature, weight, age, gender, and ethnicity differences; and 2) most of between-individual TBK variation could be explained by total appendicular skeletal muscle (r2 = 0.865), whereas age, gender, and ethnicity were small but significant additional covariates (total r2 = 0.903). Our study supports the hypotheses that skeletal muscle is reduced in the elderly and that TBK provides a reasonable indirect assessment of skeletal muscle mass. These findings provide a foundation for investigating skeletal muscle mass in a wide range of health-related conditions.

Methodological challenges in measurements of functional ability in gerontological research. A review

This article addresses two important challenges in the measurement of functional ability in gerontological research: the first challenge is to connect measurements to a theoretical frame of reference which enhances our understanding and interpretation of the collected data; the second relates to validity in all stages of the research from operationalization to meaningful follow-up measurements in longitudinal studies. Advantages and disadvantages in different methods to do the measurements of functional ability are described with main focus on frame of reference, operationalization, practical procedure, validity, discriminatory power, and responsiveness. In measures of functional ability it is recommended: 1) always to consider the theoretical frame of reference as part of the validation process (e.g., the theory of "The Disablement Process"; 2) always to assess whether the included activities and categories are meaningful to all people in the study population before they are combined into an index and before tests for construct validity; 3) not to combine mobility, PADL and IADL in the same index/scale; 4) not to use IADL as a health-related functional ability measure or, if used, to ask whether problems with IADL or non-performance of IADL are caused by health-related factors; 5) always to make analyses of functional ability for men and women separately as patterns of functional ability and patterns of associations between other variables and functional ability often vary for men and women; and 6) to exclude the dead in analyses of change in functional ability if the focus is on predictors of deterioration in functional ability.

Identifying hospitalized older patients at varying risk for physical performance decline: a new approach

OBJECTIVE

A classification tree analysis identifies patient groups at varying risk for decline in physical performance 1 year after hospitalization.

DESIGN

Prospective cohort study.

SETTING

Tertiary care VAMC.

PARTICIPANTS

A total of 507 acutely ill hospitalized male veterans aged 65 years and older.

MEASUREMENTS

Eighteen admission characteristics were considered as potential predictors: demographic data, medical diagnoses, functional status (e.g., ADL and IADL), geriatric conditions (e.g., incontinence, vision impairment, weight change), mental status, depression, and physical functioning (measured by self-report (MOS-PFR) and the Physical Performance and Mobility Examination (PPME)). Outcome measure was change in PPME status at 12-months post-admission.

RESULTS

Patients with the greatest risk for decline had both high baseline physical performance (PPME > or = 9) and at least moderate self-report limitations on physical functioning (MOS-PFR < or = 36, mean = 30.8). Patients with the lowest risk of decline had impaired baseline physical performance (PPME < or = 8) but fewer self-report limitations on physical functioning (MOS-PFR > or = 31, mean = 37.4) and two or less geriatric conditions.

CONCLUSIONS

The predictive role of self-report functioning suggests that perception of the impact of health on one's own physical functioning is associated with future performance. The number of geriatric conditions is also an important predictor of physical performance change. By identifying patient risk groups based on geriatric conditions, physical performance, and self-report physical functioning, future targeting strategies may improve physical performance outcomes for hospitalized older adults.

Prolonged duration of standing up is an early dopa-sensitive abnormality in Parkinson's disease

We studied the influence of dopaminergic medication on the duration of standing up, static posture and gait in five patients with Parkinson's disease (Hoehn and Yahr stage 1.5 to 3) and four healthy controls, using an optoelectronic camera system. Duration of standing up was prolonged in patients, while static posture and gait were largely unaffected. The prolonged duration of standing up was corrected by dopaminergic medication. These results suggest that an increased duration of standing up is a relatively early and dopa-sensitive abnormality in Parkinson's disease.

A race- and gender-specific replication of five dimensions of functional limitation and disability

Activity of daily living (ADL) and instrumental ADL (IADL) data from the 1989 National Long-Term Care Survey (NLTCS) are used to replicate two domains of functional status with a total of five dimensions among them. LISREL analysis of the 14,415 Black and White older adults obtained from the 1989 NLTCS screen replicates three ADL disability dimensions (basic, household, and advanced) with few modifications, except among Black males. Similarly, analysis of the 4,297 Black and White disabled older adults replicates five functional status dimensions (3 ADL disability dimensions plus lower- and upper-body functional limitation dimensions) with few modifications, except among Black males. These results suggest that improved understanding of functional status will occur from studies that take into consideration the differences between functional limitation and ADL disability. The results also indicate that further research on the validity of functional reports among Black males is needed.

Disability in older adults: evidence regarding significance, etiology, and risk

OBJECTIVES

This article synthesizes and assesses current evidence about the importance of physical disability to older adults. It then considers the applications of research findings to clinical geriatrics practice.

RESULTS

Physical disability is a major adverse health outcome associated with aging. Certain subgroups of older adults, including individuals with mobility difficulty, with preclinical functional changes, and persons who are hospitalized, are at particularly high risk of becoming disabled or experiencing disability progression. The major underlying causes of physical disability are chronic diseases, including both acute events, such as hip fracture and stroke and slowly progressive diseases such as arthritis and heart disease. These diseases appear to have task-specific effects; understanding this may assist in setting treatment and prevention goals. Comorbidity, particularly certain combinations of chronic diseases, is a strong risk factor for disability in itself. Recent trials indicate that clinical interventions may be able to prevent onset or progression of disability.

CONCLUSIONS

Available evidence now suggests clinical approaches to both treatment and prevention of disability and directions for defining optimal clinical care for the future.

Self-report of difficulty in performing functional activities identifies a broad range of disability in old age

OBJECTIVE

To describe a broad range of physical disability by examining the association between a four-level measure of disability, based on self-report of difficulty in performing functional activities, and previously identified risk factors for disability.

DESIGN

Cross-sectional.

SETTING

Community-based.

PARTICIPANTS

A total of 2373 noninstitutionalized men and women aged 65 and older from the Veneto Region of Italy.

MEASUREMENTS

Odds ratios for the association of the four levels of disability (none, mild, moderate, and ADL disability) differentiated by this new measure with known risk factors for physical disability.

MAIN RESULTS

This summary measure of physical disability distinguished older persons with disability from the population typically classified as nondisabled. Twenty-one percent of study participants were identified as having Activities of Daily Living (ADL) disability (defined as self-report of difficulty in one or more ADLs), and an additional 40% had mild or moderate disability based on degree of difficulty in Instrumental Activities of Daily Living (IADLs) and physical functional activities. Hip fracture and lower extremity performance were strongly independently associated with each level of disability. The association of a range of established risk factors for disability and health care utilization measures with the levels of disability identified in our study, and the trend toward increasing odds with increasing disability, provide evidence of the construct validity of this measure.

CONCLUSIONS

Self-report of difficulty in performing functional activities identifies older persons with physical disability not ascertained by self-report of the need for help, the measure typically used to identify disability in older populations. Further studies should evaluate the potential for self-reported difficulty in functional activities to predict important disability-related outcomes.

The relationship between physical performance measures and independence in instrumental activities of daily living. The FICSIT Group. Frailty and Injury: Cooperative Studies of Intervention Trials

OBJECTIVES

Understanding the relationship between physical capacity and functional status is required to design exercise interventions to maintain independent living. This study assessed the importance of physical performance in maintaining independence in Instrumental Activities of Daily Living (IADL).

DESIGN

A pre-planned meta-analysis of cross-sectional data from six sites of the Frailty and Injury: Cooperative Studies of Intervention Trials (FICSIT). Linear regression was used to estimate the relationship between physical performance and IADL.

PARTICIPANTS

2190 community-dwelling older subjects.

MEASUREMENTS

IADL was the dependent variable; gait velocity, balance function, grip strength and chair rise time were the predictor variables. Age, gender, education, falls self-efficacy, and cognitive status were covariates.

RESULTS

Gait velocity, balance function, and grip strength were independently related to IADL deficits, after correcting for covariates. The linear slopes were relatively steep. For gait, a decrease of 0.1 m s-1 was associated with 0.10 (95% Cl: 0.17, 0.04) increase in IADL deficits, which is equivalent to 1 ADL deficit in 10 subjects. The linear slopes for hand grip and balance were similar or steeper. In the sites where chair stand time was measured, an increase of 1 second in the time to rise was associated with a 0.14 (0.04, 0.24) increase in IADL deficits. The relationships found in the meta-analytic analysis were consistent across sites which enrolled subjects with widely varying levels of physical performance.

CONCLUSION

Simple measures of physical performance were strongly associated with IADL independence after correcting for many previously identified predictors of functional status. The data from this meta-analysis support testing interventions designed to improve physical performance to determine whether improved performance can maintain or improve independence in IADLs.

Measuring functional status: cross-sectional and longitudinal associations between performance and self-report (Zutphen Elderly Study 1990-1993)

We investigated cross-sectional as well as longitudinal associations between performance-based measures of functional status and self-reported measures of functional status. In the Zutphen Elderly Study, 494 men, born between 1900 and 1920, were examined in 1990, of whom 303 were reexamined in 1993. A performance score was constructed on the basis of four tests: standing balance, walking speed, ability to rise from a chair, and external shoulder rotation. Self-reported functional status was based on disabilities in basic activities of daily living, mobility, and instrumental activities of daily living. A hierarchic disability scale was constructed. Cross-sectional correlation coefficients between the performance score and the disability scale were 0.22 in 1990 and 0.39 in 1993. Correlations were highest between the test for walking speed and self-reported mobility and IADL, and between the test for external shoulder rotation and self-reported disabilities in basic activities of daily living. The correlation between the 3-year changes in performance and in self-report was 0.20 (p < 0.001). Both performance and self-report at baseline predicted performance and self-report after 3 years. Performance-based measures of functional status are cross-sectionally and longitudinally associated at modest levels with self-reported disabilities. Performance measures and self-reported measures are complementary, but do not measure the same construct.

Effect of age and severity of disability on short-term variation in walking speed: the Women's Health and Aging Study

Standardized objective measures of human performance have been introduced in clinical and epidemiologic studies of older populations. Reliability of these measures has usually been estimated by comparing two measures obtained in the same person. However, no information is available on variability of multiple measures collected serially over short time intervals. This study uses data from the Weekly Disability Study, a component of the Women's Health and Aging Study, to describe fluctuations in physical performance over multiple, consecutive time intervals. Walking speed was measured weekly over a 6-month period in 99 older women affected by mild to severe disability. Overall, 2120 observations were explored using techniques developed for the analysis of repeated measures. Results showed that the correlations between observations in the same person were inversely related to their separation in time. The decay in the autocorrelation function was steeper in the least disabled. However, even with 20-week separations in assessments, correlations remained above 0.6 in all age and severity of disability subgroups. Changes over time in performance differed somewhat between disability subgroups, but the relative performance across subgroups remained stable over the entire course of the study. A clear learning effect was found only in those in the middle disability subgroup. Results support the utilization of repeated measures of physical performance in research that evaluates older persons over time.

Physical Performance Measures for Characterizing High Functioning Older Persons

The goal of this study was to identify methods for characterizing high-functioning older adults living in the community. The subjects were 495 older adults from the Longitudinal Interdisciplinary Study on Aging conducted by the Tokyo Metropolitan Institute of Gerontology. Physical performance measures included grip strength, walking at preferred and maximum speeds, one-leg standing with eyes open, and finger tapping rate. Performance scores were created by summing each categorical score. Consistent differences were found among age groups and genders. Scores were lower in subjects who had stroke or diabetes than in those without these conditions. These results suggest that physical performance measures have both discriminant validity and construct validity, which make them useful methods for characterizing high-functioning older persons.

Inner-city older blacks have high levels of functional disability

OBJECTIVES

To describe the frequency and severity of functional problems in two groups of noninstitutionalized inner-city blacks aged 70 years and older contrasted with results from appropriate groups of white and black older adults and with the goals of the Healthy People 2000 program.

DESIGN

Cross-sectional descriptive study.

SETTING

Community-based samples.

PARTICIPANTS

A population-based sample of 416 older adults living in a 3.5-square mile catchment area in north St. Louis (NSL), Missouri, and a sample of 197 older residents living in public housing in East St. Louis (ESL), Illinois.

MEASUREMENTS

Health status, preventive health activities, health services utilization, and risks for progressive frailty were assessed by self report and observation using well validated, standardized instruments. Whenever possible, comparison data were derived from national datasets, original samples used to validate the measures, and other useful comparison groups.

RESULTS

The NSL sample had somewhat better health status and risk for progressive disability than the ESL sample. However, compared with national or regional reference groups using age-gender adjustments, both study groups demonstrated increased levels of dependence in intermediate activities of daily living, restricted activity days, inability to walk one-half mile without assistance, reported poor vision, living alone, and limited income compared with both older whites and blacks, and increased levels of worsening health, inability to perform heavy work around the house, never walking a mile or more, and currently unmarried versus whites with variable decrements versus blacks. Contrasted with other comparison groups, the two samples had increased body fat; consistent decrements in gait speed, timed chair stands, timed one-leg balance, and frequency of preventive exercise; and lower levels of dental care; results relative to physician visits and hospital days were mixed. They also had high levels of measured visual and hearing impairments, unmet needs for home delivered meals, and problems with false teeth. Deficiencies compared with the goals of Healthy People 2000 were large.

CONCLUSIONS

The special attributes of inner-city blacks, including poverty and access to and acceptance of remedial programs, will have to be considered if the goals of Healthy People 2000 are to be met in this important and growing segment of older Americans. 44:0000-0000, 1996.

Prospective value of self-report and performance-based tests of functional status for 18-month outcomes in elderly patients

To determine predictors of death, nursing home placement and hospital admission, a prospective study was carried out in a university-affiliated geriatric hospital and a general practice. One hundred and thirty-five patients consecutively admitted from home to the geriatric hospital and discharged home again (site 1), and 144 patients, aged 70 years and over, of a general practice (site 2) were recruited for a comprehensive geriatric assessment program. At baseline, none was completely dependent on others, or severely demented. At follow-up after 18 months, 46 subjects (17%) had died, 20 subjects (7%) had been institutionalized, and 79 had been admitted to hospital (28%) in the interim. Univariate analysis demonstrated a significant association between Barthel Activities of Daily Living (ADL), Lawton-Brody Instrumental Activities of Daily Living (IADL), Mini-Mental State Examination (MMSE), Balance and Gait Evaluation, Timed "Up and Go", Timed Test of Money Counting. Grip-Strength and Williams Board Test, and death as well as nursing home placement. Barthel-ADL were significantly correlated with hospital admission. In a logistic regression analysis, Barthel-ADL were independent predictors for death; Barthel-ADL, Timed "Up and Go", Timed Test of Money Counting, and Williams Board Test were independent predictors for nursing home placement. No independent predictor was found for hospital admission. It is concluded that self-report and performance-based measures of functional capabilities are useful instruments to identify patients at risk for nursing home placement and death. Factors contributing to hospital admissions are other than those measured by the applied tests.

Consistency and change in functional status among older adults over time

Consistency and change between 1984 and the last reinterview (either two, four, or six years later) on 22 individual functional status markers and the five summary scales that they form are examined among the 5,986 members of the Longitudinal Study on Aging who were reinterviewed at least once. At baseline, at least three-fifths of the respondents are without limitations on any individual marker. At the last reinterview, at least 43.4% of the respondents are without such limitations. Among those who had limitations at baseline, at least one-fifth get better. For those without limitations at baseline, one-seventeenth to two-fifths get worse. Difficulties in walking and doing heavy housework were the most common, most likely to develop, and least likely to resolve of any of the ADL or IADL items, and lower body limitations were more common, more likely to develop, and less likely to resolve than upper body limitations. Linear panel analysis of the five summary scales indicates that the top predictors of increased functional limitation are baseline levels of functional limitation, older age, decedent status, and poorer perceived health (in that order). Other less consistent and less robust predictors include the length of the exposure window, being female, having a history of arthritis, lower educational attainment, having fewer nonkin social supports, higher prior physician visit levels, and not living alone.

Survival in the oldest old: death risk factors in old and very old subjects

Factors predicting death in the ninth decade of life may differ from predictors in younger age groups. A prospective study was carried out on 210 subjects entering a residential home at the age of 68 to 79 years and of 287 subjects aged greater than or equal to 80 years who included 91 survivors from the first group; all subjects were followed until 78% of them had died. A Cox analysis was carried out with death as end point and 13 potential risk factors as covariates. Mildly impaired mobility at entry, defined as the need for help to walk 300-400 yards for various reasons, smoking, bacteriuria, and presence of ECG abnormalities were significant death risk predictors before age 80. Beyond this age, only mildly impaired mobility and serum cholesterol levels less than or equal to 5.9 mmol/L, as compared with levels greater than or equal to 8.0 mmol/L, remained significant. Higher hematocrit levels were predictors of survival before and after age 80. Systolic blood pressure, age, sex, weight, and socioeconomic status had no effect in either group. The data show that survival after age 80 is related only to adequate physical mobility and high hematocrit and cholesterol levels, regardless of the levels of other common risk factors.

Hospital admission risk profile (HARP): identifying older patients at risk for functional decline following acute medical illness and hospitalization

OBJECTIVES

To develop and validate an instrument for stratifying older patients at the time of hospital admission according to their risk of developing new disabilities in activities of daily living (ADL) following acute medical illness and hospitalization.

DESIGN

Multi-center prospective cohort study.

SETTING

Four university and two private non-federal acute care hospitals.

PATIENTS

The development cohort consists of 448 patients and the validation cohort consists of 379 patients who were aged 70 and older and who were hospitalized for acute medical illness between 1989 and 1992.

MEASUREMENTS

All patients were evaluated on hospital admission to identify baseline demographic and functional characteristics and were then assessed at discharge and 3 months after discharge to determine decline in ADL functioning.

RESULTS

Logistic regression analysis identified three patient characteristics that were independent predictors of functional decline in the development cohort: increasing age, lower admission Mini-Mental Status Exam scores, and lower preadmission IADL function. A scoring system was developed for each predictor variable and patients were assigned to low, intermediate, and high risk categories. The rates of ADL decline at discharge for the low, intermediate, and high risk categories were 17%, 28%, and 56% in the development cohort and 19%, 31%, and 55% in the validation cohort, respectively. Patients in the low risk category were significantly more likely to recover ADL function and to avoid nursing home placement during the 3 months after discharge.

CONCLUSION

Hospital Admission Risk Profile (HARP) is a simple instrument that can be used to identify patients at risk of functional decline following hospitalization. HARP can be used to identify patients who might benefit from comprehensive discharge planning, specialized geriatric care, and experimental interventions designed to prevent/reduce the development of disability in hospitalized older populations.

A trial of annual in-home comprehensive geriatric assessments for elderly people living in the community

BACKGROUND AND METHODS

The prevention of disability in elderly people poses a challenge for health care and social services. We conducted a three-year, randomized, controlled trial of the effect of annual in-home comprehensive geriatric assessment and follow-up for people living in the community who were 75 years of age or older. The 215 people in the intervention group were seen at home by gerontologic nurse practitioners who, in collaboration with geriatricians, evaluated problems and risk factors for disability, gave specific recommendations, and provided health education. The 199 people in the control group received their regular medical care. The main outcome measures were the prevention of disability, defined as the need for assistance in performing the basic activities of daily living (bathing, dressing, feeding, grooming, transferring from bed to chair, and moving around inside the house) or the instrumental activities of daily living (e.g., cooking, handling finances and medication, housekeeping, and shopping), and the prevention of nursing home admissions.

RESULTS

At three years, 20 people in the intervention group (12 percent of 170 surviving participants) and 32 in the control group (22 percent of 147 surviving participants) required assistance in performing the basic activities of daily living (adjusted odds ratio, 0.4; 95 percent confidence interval, 0.2 to 0.8; P = 0.02). The number of persons who were dependent on assistance in performing the instrumental activities of daily living but not the basic activities did not differ significantly between the two groups. Nine people in the intervention group (4 percent) and 20 in the control group (10 percent) were permanently admitted to nursing homes (P = 0.02). Acute care hospital admissions and short-term nursing home admissions did not differ significantly between the two groups. In the second and third years of the study, there were significantly more visits to physicians among the participants in the intervention group than among those in the control group (mean number of visits per month, 1.41 in year 2 and 1.27 in year 3 in the intervention group, as compared with 1.11 and 0.92 visits, respectively, in the control group; P = 0.007 and P = 0.001, respectively). The cost of the intervention for each year of disability-free life gained was about $46,000.

CONCLUSIONS

A program of in-home comprehensive geriatric assessments can delay the development of disability and reduce permanent nursing home stays among elderly people living at home.