Showing papers in "Journals of Gerontology Series A-biological Sciences and Medical Sciences in 2000"

Lower Extremity Function and Subsequent Disability Consistency Across Studies, Predictive Models, and Value of Gait Speed Alone Compared With the Short Physical Performance Battery

Abstract: Background. Although it has been demonstrated that physical performance measures predict incident disability in previously nondisabled older persons, the available data have not been fully developed to create usable methods for determining risk profiles in community-dwelling populations. Using several populations and different follow-up periods, this study replicates previous findings by using the Established Populations for the Epidemiologic Study of the Elderly (EPESE) performance battery and provides equations for the prediction of disability risk according to age, sex, and level of performance. Methods. Tests of balance, time to walk 8 ft, and time to rise from a chair 5 times were administered to 4,588 initially nondisabled persons in the four sites of the EPESE and to 1,946 initially nondisabled persons in the Hispanic EPESE. Follow-up assessment for activity of daily living (ADL) and mobility-related disability occurred from 1 to 6 years later. Results. In the EPESE, compared with those with the best performance (EPESE summary performance score of 10‐ 12), the relative risks of mobility-related disability for those with scores of 4‐6 ranged from 2.9 to 4.9 and the relative risk of disability for those with scores of 7‐9 ranged from 1.5 to 2.1, with similar consistent results for ADL disability. The observed rates of incident disability according to performance level in the Hispanic EPESE agreed closely with rates predicted from models developed from the EPESE sites. Receiver operating characteristic curves showed that gait speed alone performed almost as well as the full battery in predicting incident disability. Conclusions. Performance tests of lower extremity function accurately predict disability across diverse populations. Equations derived from models using both the summary score and the gait speed alone allow for the estimation of risk of disability in community-dwelling populations and provide valuable information for estimating sample size for clinical trials of disability prevention.

Prospective Study of the Impact of Fear of Falling on Activities of Daily Living, SF-36 Scores, and Nursing Home Admission

Abstract: Background. The aim of this study was to assess the impact of fear of falling on the health of older people. Methods. A total of 528 subjects (mean age 77 years) were recruited from two hospitals in Sydney, Australia, and followed for approximately 12 months. Eighty-five subjects died during follow-up, and 31 were admitted to an aged care institution. Tinetti’s Falls Efficacy Scale (FES) was successfully administered to 418 subjects as part of the baseline assessment. Among those with baseline FES scores, ability to perform 10 activities of daily living (ADLs) was assessed at baseline and follow-up in 307 subjects, and SF-36 scores were assessed at baseline and follow-up in 90 subjects recruited during the latter part of the study. Falls during follow-up were identified using a monthly falls calendar. Results. Compared with those with a high fall-related self-efficacy (FES score 5 100), those with a low fall-related self-efficacy (FES score # 75) had an increased risk of falling (adjusted relative risk 2.09, 95% confidence interval [CI] 1.31‐3.33). Those with poorer fall-related self-efficacy had greater declines in ability to perform ADLs ( p , .001): the total ADL score decreased by 0.69 activities among persons with low FES scores ( # 75) but decreased by only 0.04 activities among persons with FES scores of 100. Decline in ADLs was not explained by the higher frequency of falls among persons with low FES scores. SF-36 scores (particularly scores on the Physical Function and Bodily Pain subscales) tended to decline more among persons with poor fall-related self-efficacy. Nonfallers who said they were afraid of falling had an increased risk of admission to an aged care institution. Conclusions. Fear of falling has serious consequences for older people. Interventions that successfully reduce fear of falling and improve fall-related self-efficacy are likely to have major health benefits.

Recovery From Hip Fracture in Eight Areas of Function

Abstract: Background. This report describes changes in eight areas of functioning after a hip fracture, identifies the point at which maximal levels of recovery are reached in each area, and evaluates the sequence of recuperation across multiple functional domains. Methods . Community-residing hip fracture patients ( n 5 674) admitted to eight hospitals in Baltimore, Maryland, 1990‐1991, were followed prospectively for 2 years from the time of hospitalization. Eight areas of function (i.e., upper and lower extremity physical and instrumental activities of daily living; gait and balance; social, cognitive, and affective function) were measured by personal interview and direct observation during hospitalization at 2, 6, 12, 18, and 24 months. Levels of recovery are described in each area, and time to reach maximal recovery was estimated using Generalized Estimating Equations and longitudinal data. Results. Most areas of functioning showed progressive lessening of dependence over the first postfracture year, with different levels of recovery and time to maximum levels observed for each area. New dependency in physical and instrumental tasks for those not requiring equipment or human assistance prefracture ranged from as low as 20.3% for putting on pants to as high as 89.9% for climbing five stairs. Recuperation times were specific to area of function, ranging from approximately 4 months for depressive symptoms (3.9 months), upper extremity function (4.3 months), and cognition (4.4 months) to almost a year for lower extremity function (11.2 months). Conclusions . Functional disability following hip fracture is significant, patterns of recovery differ by area of function, and there appears to be an orderly sequence by which areas of function reach their maximal levels.

Association of Muscle Power With Functional Status in Community-Dwelling Elderly Women

Abstract: Background. Identification of the physiologic factors most relevant to functional independence in the elderly population is critical for the design of effective interventions. It has been suggested that muscle power may be more directly related to impaired physical performance than muscle strength in elderly persons. We tested the hypothesis that peak muscle power is closely associated with self-reported functional status in sedentary elderly community-dwelling women. Methods. We used baseline data that were collected as part of a 1-year randomized controlled clinical trial of a combined program of strength, power, and endurance training in 80 elderly women (mean age 74.8 6 5.0 years) with 3.2 6 1.9 chronic diseases, selected for baseline functional impairment and/or falls. Results. Functional status at baseline was related in univariate analyses to physiologic capacity, habitual physical activity level, neuropsychological status, and medical diagnoses. Leg power had the strongest univariate correlation to self-reported functional status ( r 5 2 .47, p , .0001) of any of the physiologic factors we tested. In a forward stepwise regression model, leg press power and habitual physical activity level were the only two factors that contributed independently to functional status ( r 5 .64, p , .0001), accounting for 40% of the variance in functional status.

Sarcopenia Current Concepts

Abstract: Sarcopenia, the loss of muscle mass and strength with age, is becoming recognized as a major cause of disability and morbidity in the elderly population. Sarcopenia is part of normal aging and does not require a disease to occur, although muscle wasting is accelerated by chronic diseases. Sarcopenia is thought to have multiple causes, although the relative importance of each is not clear. Neurological, metabolic, hormonal, nutritional, and physical-activity-related changes with age are likely to contribute to the loss of muscle mass. In this review, we discuss current concepts of the pathogenesis, treatment, and prevention of sarcopenia.

Attentional demands and postural control: the effect of sensory context.

Abstract: Background. This study used a dual task design to examine the effect of sensory context on postural stability during the concurrent performance of an attentionally demanding cognitive task in young and older adults with and without a history of imbalance and falls. Methods. A choice reaction time auditory task was used to produce changes in attention during quiet stance in six different sensory conditions that changed the availability of accurate visual and somatosensory cues for postural control. Postural stability was quantified by using forceplate measures of center of pressure in 18 young adults, 18 healthy older adults, and 18 older adults with balance impairments and a history of recent falls. Reaction time and accuracy of verbal response to the auditory task were quantified by using a repeated measures analysis of variance. Results. In young adults the auditory task did not affect postural stability in any of the sensory conditions. However, in the older adults the effect of the auditory task depended on sensory context. For healthy older adults, the addition of an auditory tone task significantly affected sway only when both visual and somatosensory cues for postural control were removed. In the balance-impaired older adults, the addition of the auditory task significantly affected postural stability in all sensory conditions. In addition, as sensory conditions became more difficult, older adults who had been able to maintain stability in a single task context lost balance when performing a secondary task. Conclusion. Results suggest that with aging, attentional demands for postural control increase as sensory information decreases. In addition, the inability to allocate sufficient attention to postural control under multitask conditions may be a contributing factor to imbalance and falls in some older adults.

Muscle Strength and Body Mass Index as Long-Term Predictors of Mortality in Initially Healthy Men

Abstract: BACKGROUND Muscle weakness, low body weight, and chronic diseases are often observed in the same people; however, the association of muscle strength with mortality, independent of disease status and body weight, has not been elucidated. The aim was to assess hand grip strength as a predictor of all-cause mortality within different levels of body mass index (BMI) in initially disease-free men. METHODS Mortality was followed prospectively over 30 years. Maximal hand grip strength tests and BMI assessments were done at baseline in 1965 to 1970. The participants were 6040 healthy men aged 45 to 68 years at baseline living on Oahu, Hawaii. RESULTS The death rates per 1000 person years were 24.6 in those with BMI or = 25. For grip strength tertiles, the mortality rates were 24.8 in the lowest, 18.5 in the middle, and 14.0 in the highest third. In Cox regression models, within each tertile of grip strength, BMI showed only minimal effect on mortality. In contrast, in each category of BMI there was a gradient of decreasing mortality risk with increasing grip strength. Among those with BMI or =25, the RRs were 1.39 (1.16-1.65) in the lowest, 1.27 (1.08-1.49) in the middle, and 1.14 (0.98-1.32) in the highest third of grip strength. Models were adjusted for age, education, occupation, smoking, physical activity, and body height. CONCLUSIONS In healthy middle-aged men, long-term mortality risk was associated with grip strength at baseline, independent of BMI. The possible interpretation of the finding is that early life influences on muscle strength may have long-term implications for mortality. Additionally, higher strength itself may provide greater physiologic and functional reserve that protects against mortality.

Preclinical Mobility Disability Predicts Incident Mobility Disability in Older Women

Abstract: Background. Physical disability and dependency are serious, and frequent, adverse health outcomes associated with aging and resulting from chronic disease. Reasoning has suggested that there might be a preclinical, intermediate phase of disablement which might develop in parallel with progression of underlying disease and precede and predict disability. Definition of this stage could provide a basis for screening and early intervention to prevent disability. The objective of this study was to determine preclinical functional predictors of incident mobility difficulty and provide evidence for a preclinical stage of disability. Methods. A prospective, population-based cohort study was carried out in Baltimore, Maryland, with two evaluations 18 months apart. The participants were 436 community-dwelling women, 70-80 years of age at baseline, not cognitively impaired, and reporting difficulty in no areas, or only one area, of physical function (primarily mobility), who were participating in the Women's Health and Aging Study II. Participants were recruited from a population-based, age-stratified random sample. Incident mobility disability was studied in the subset without such disability at baseline. The main outcome measure was selfreported incident difficulty walking /i mile or climbing up 10 steps. Results. At baseline, 69.3% of the cohort reported no difficulty with mobility. After 18 months, 16.0 and 11.7% of this group reported incident difficulty walking 1/2 mile or climbing up 10 steps, respectively. Those reporting baseline task modification due to underlying health problems, our measure of preclinical disability, were at three- to fourfold higher odds of progressing to difficulty than were those without such modification. In multivariate logistic regression analyses, this self-report measure, task modification without difficulty, and objective measures of performance were independently and jointly predictive of incident mobility difficulty. Specifically, for incident difficulty walking /i mile, self-reported task modification odds ratio (OR) = 3.67, walking speed (.5 m/s difference) OR = 2.16; for incident difficulty climbing up 10 stairs, OR for task modification = 3.84, for stair climb speed (]A step/s difference) = 2.08 (95% CI did not include 1 for any). Covariates, age, living alone, number of chronic diseases, depression score, knee strength, and balance by functional reach, were not significant predictors in either model. Conclusions. Two indicators of functional changes in older women without mobility difficulty, self-report of modification of method of doing a task in the absence of difficulty and performance measures, are independent and strong predictors of risk of incident mobility disability. The self-report measure provides substantial strength in predicting risk of incident disability across the full range of performance, and may identify a vulnerable point at which other risk factors act to cause transitions to disability. Together, the preclinical indicators identify a subset of high-functioning older women who are at high risk of mobility disability, and provide a potential basis for screening for disability risk and targeting interventions to prevent mobility disability.

Cross-sectional and Prospective Relationships of Interleukin-6 and C-Reactive Protein With Physical Performance in Elderly Persons MacArthur Studies of Successful Aging

Abstract: Although IL-6 has been shown to predict onset of disability in older persons and both IL-6 and CRP are associated with motality risk, these markers of inflammation have only limited associations with physical performance, except for walking measures and grip strength at baseline, and do not predict change in performance 7 years later in a high-functioning subset of older adults.

Effects of a Group Exercise Program on Strength, Mobility, and Falls Among Fall-Prone Elderly Men

Abstract: Objectives. This randomized controlled trial studied the effects of a low- to moderate-intensity group exercise program on strength, endurance, mobility, and fall rates in fall-prone elderly men with chronic impairments. Methods. Fifty-nine community-living men (mean age � 74 years) with specific fall risk factors (i.e., leg weakness, impaired gait or balance, previous falls) were randomly assigned to a control group (n � 28) or to a 12-week group exercise program (n � 31). Exercise sessions (90 minutes, three times per week) focused on increasing strength and endurance and improving mobility and balance. Outcome measures included isokinetic strength and endurance, five physical performance measures, and self-reported physical functioning, health perception, activity level, and falls. Results. Exercisers showed significant improvement in measures of endurance and gait. Isokinetic endurance increased 21% for right knee flexion and 26% for extension. Exercisers had a 10% increase ( p � .05) in distance walked in six minutes, and improved ( p � .05) scores on an observational gait scale. Isokinetic strength improved only for right knee flexion. Exercise achieved no significant effect on hip or ankle strength, balance, self-reported physical functioning, or number of falls. Activity level increased within the exercise group. When fall rates were adjusted for activity level, the exercisers had a lower 3-month fall rate than controls (6 falls/1000 hours of activity vs 16.2 falls/1000 hours, p � .05). Discussion. These findings suggest that exercise can improve endurance, strength, gait, and function in chronically impaired, fall-prone elderly persons. In addition, increased physical activity was associated with reduced fall rates when adjusted for level of activity.

Age Effects on the Temporal Evolution of Isometric and Swallowing Pressure

Abstract: Background. The tongue plays a key role in bolus propulsion through the oropharyngeal chamber. In this study, possible age effects on the magnitude and timing of lingual pressure generation were analyzed. Methods. Oral pressure was measured during isometric and swallowing tasks for 10 elderly (mean age 5 81 years) and 10 young (mean age 5 51 years) subjects. Three trials each of the isometric task and swallows of three different boluses (3 ml semisolid, 3 ml liquid, and 10 ml liquid) were performed by each subject. The timing and magnitude of isometric and swallowing pressure generation along with the pattern of the swallowing pressure waveform were analyzed. Results. Whereas maximum lingual isometric pressures decreased with age ( p , .001), no significant age difference was found for swallowing pressure. Time taken to reach peak pressure also was reduced with age in both the isometric task and swallows of liquid boluses ( p , .05), while no significant age effect was found for semisolid swallows. Finally, only elderly subjects showed a pattern of liquid swallowing pressure generation in which multiple lingual gestures were required to reach peak pressure (termed “pressure building”), a pattern demonstrated by both young and elderly groups for semisolids. Conclusions. Decreased lingual strength with age combined with unchanging swallowing pressure leads to a decreased “pressure reserve,” perhaps leaving older individuals more at risk for dysphagia resulting from insults directly or indirectly to the swallowing system. Additionally, swallowing is generally “slowed” with age, apparently due to both central and peripheral factors, and this change may have an impact on bolus flow outcomes.

Lower Extremity Performance in Nondisabled Older Persons as a Predictor of Subsequent Hospitalization

Abstract: Background. This study examines, in initially nondisabled older persons, the impact of reduced lower extremity performance on subsequent hospitalizations. Methods. A 4-year prospective cohort study was conducted among 3381 persons, aged 71 years and older, who initially reported no disability. At baseline, lower extremity performance was measured by an assessment of standing balance, a timed 2.4-m walk, and a timed test of rising from a chair five times. Data on subsequent hospital admissions and discharge diagnoses over 4 years were obtained from the Medicare database. Results. During the follow-up period, nondisabled persons with poor lower extremity performance spent significantly more days in the hospital (17.7 days) than those with intermediate and high performance (11.6 and 9.7 days, respectively). Poor lower extremity performance in nondisabled persons significantly predicted subsequent hospitalization over 4 years (relative risk for hospitalization in those with poor vs high performance: 1.78; 95% confidence interval, 1.45‐2.17). This increased hospitalization risk could not be explained by several indicators of baseline health status. Increased hospitalization risks were especially found for geriatric conditions, such as dementia, decubitus ulcer, hip fractures, other fractures, pneumonia, dehydration, and acute infections.

Physical and Performance Measures for the Identification of Mild to Moderate Frailty

Abstract: Background The relative importance and association of factors contributing to physical frailty in elderly persons are unclear. Methods Physical measures of upper and lower extremity strength, range of motion, balance, coordination, sensation, and gait were evaluated in relation to scores obtained on a 36-point physical performance test (PPT) in 107 elderly subjects. Results Scores on the PPT were significantly associated with the measures of strength and balance, gait, several range of motion values, and sensation. Subjects were also grouped according to score on the PPT as not frail (32-36 points), mildly frail (25-31 points), or moderately frail (17-24 points). ANOVA followed by Bonferroni post hoc analyses were used to examine the relationships of physical measures to this index of frailty. Balance measures, an obstacle course, the Berg scale, the full tandem portion of the Romberg test, and fast gait speed were significantly different among the three groups. Multiple stepwise regression analyses indicated that the strongest combination of variables, explaining 73% of all the variance in the PPT, included obstacle course performance, hip abduction strength, the semitandem portion of the Romberg test, and coordination (pegboard). Conclusions Results provide further insight into the relative importance of factors that contribute to frailty and factors that should be considered in treatment planning for the remediation of physical frailty in old adults.

Comparative effects of two physical activity programs on measured and perceived physical functioning and other health-related quality of life outcomes in older adults.

Abstract: Background Although inactivity is an important contributor to impaired functioning and disability with age, little is known concerning how improvements in physical functioning and well-being in older adults vary with the type of physical activity undertaken. Methods One hundred three adults age 65 years and older, recruited via population-based methods, were randomized to 12 months of community-based, moderate-intensity endurance and strengthening exercises (Fit & Firm) or stretching and flexibility exercises (Stretch & Flex). A combination of class- and home-based exercise formats was used. Measured and self-rated physical performance along with perceived functioning and well-being were assessed pre- and postintervention. Results Fit & Firm subjects showed greater 12-month improvements in both measured and self-rated endurance and strength compared to Stretch & Flex subjects. Stretch & Flex subjects reported greater improvements in bodily pain, and Stretch & Flex men evidenced greater improvements in flexibility relative to Fit & Firm subjects. Although overall exercise adherence was high in both exercise conditions (approximately 80%), subjects in both conditions showed better adherence to the home- versus class-based portions of their exercise prescriptions. Conclusions Community-based programs focusing on moderate-intensity endurance and strengthening exercises or flexibility exercises can be delivered through a combination of formats that result in improvement in important functional and well-being outcomes. This represents one of the first studies to report significant improvements in an important quality of life outcome-bodily pain-with a regular regimen of stretching and flexibility exercises in a community-based sample of older adults.

Age-Related Differences in Laterally Directed Compensatory Stepping Behavior

Abstract: Background. Lateral falls are common in older adults and are associated with an elevated risk of hip fracture, compared with falls in other directions. Although rapid stepping movements can play an important functional role in maintaining balance, control of lateral stepping is a complex and demanding motor task. This study examined whether there are age-related differences in the stepping behavior used to recover from lateral loss of balance. Methods. Rapid stepping reactions were evoked in healthy, active young (aged 20‐30 years; N 5 10) and older (aged 65‐73 years; N 5 10) volunteers by means of a sudden unpredictable motion of a platform on which the subject either stood quietly or walked in place. Subjects were instructed to respond naturally. Video analysis was performed to characterize the patterns of limb movement evoked by lateral platform motion. Results. In responding to lateral perturbation of stance, the older adults were much more likely than the young adults to take multiple steps or use arm reactions to regain equilibrium, particularly when attempting crossover steps. During walk-in-place trials, both young and older subjects more frequently used a sequence of side steps rather than crossovers; however, older adults were still more likely to take extra steps or use arm reactions. Collisions between swing foot and stance limb occurred in 55% of walk-in-place trials in older adults versus only 8% in young adults. Conclusions. Control of lateral-stepping reactions appears to create difficulties for active and healthy older adults above and beyond previously reported problems in controlling forward and backward stepping. Impaired control of lateral-stepping reactions may be an early indicator of increased risk for lateral falls and hip fracture and should be an important consideration in the development of clinical approaches to predicting and preventing falls and related injuries. HERE is little doubt that difficulty in controlling balance is a major contributor to an increased risk of expe

A Prospective Study of Laboratory and Clinical Measures of Postural Stability to Predict Community-Dwelling Fallers

Abstract: Background. The identification of specific risk factors for falls in community-dwelling elderly persons is required to detect early changes and permit a preventative approach to management. This study determines the ability of various laboratory measures and clinical tests of postural stability to prospectively predict fallers in community-dwelling elderly women. Methods. One hundred elderly women (65‐86 years, mean age 73 6 5 years) performed a reaction-time step task, a limits of stability, and a quiet stance balance task. Postural muscle timing and movement speed were recorded during the step task. Center of pressure (COP) motion was recorded in quiet stance and at the limits of stability. Four common clinical balance tests were performed, and balance confidence, medical and activity history questionnaires were completed. Subjects were followed up regularly for a 6-month period following testing to determine the frequency and characteristics of any falls that occurred. Predictive capabilities of the balance measures to determine fallers were determined through logistic regression models. Results. The clinical balance tests investigated were not able to predict fallers in this community-dwelling elderly population. A combination of variables from the laboratory tasks provided the best overall prediction rate (77%) of fallers (sensitivity 51%) and nonfallers (specificity 91%) from laboratory measures. Of these, step movement time and gluteus medius onset times were the factors best able to predict fallers. Alone, measures of COP motion in quiet stance and at the limits of stability had a poor ability to predict fallers, although they could correctly identify most nonfallers. Prediction was not significantly improved when clinical balance test results were added to the most predictive laboratory measures. Conclusions. Not all older adults with a reduction in balance ability reported a fall over a 6-month period. Of those who did, a combination of measures reflective of different aspects of mediolateral postural stability during a rapid step task, quiet stance, and movement to the limits of stability were best able to predict faller status, with nonfallers better predicted than fallers. These results emphasize the importance of the multifactorial nature of falls in the communitydwelling elderly population in that the clinical and laboratory measures did not predict a high proportion of fallers.

Cognitive Influence on Postural Stability A Neuromuscular Analysis in Young and Older Adults

Abstract: Background. Previous literature indicates that attentional resources are required for recovery of postural stability. Previous studies have also examined the effect of aging on the performance of a static postural task while a secondary cognitive task is being conducted. This study describes the effect of a cognitive task on the neuromuscular response characteristics underlying reactive balance control in young versus older adults. Methods. The attentional demand on the neuromuscular system was examined in 14 young and 12 healthy older adults by analysis of the integrated electromyography activity while the adults were performing a dual-task paradigm. The primary task involved standing platform perturbations and the secondary task was a math task that involved subtraction by threes. Integrated electromyography activity was compared between the cognitive (math and balance) task versus control (balance only) task. Results. For both groups of subjects, onset latency of postural muscle responses did not change under dual-task conditions. In contrast, the amplitude of postural muscle activity was significantly affected by performance of a secondary task. When electromyography data were combined for both young and older adults, there was a decrease in muscle response amplitude in both agonist (gastrocnemius) and antagonist (tibialis anterior) muscles when the cognitive math task was performed. This was apparent at 350‐500 milliseconds from plate onset for the gastrocnemius and between 150 and 500 for the tibialis anterior. When young and older adults were compared, an age by task interaction effect was seen in muscle response amplitude for the agonist (gastrocnemius) muscle between 350 to 500 milliseconds, with older adults showing a significantly greater reduction than young adults. Conclusion. The decline of muscle activity when the secondary task was performed suggests that less attentional processing capacity was available for balance control during the dual-task paradigm. The results also indicate that the dual-task activity has a greater impact on balance control in the older adults than in the young adults. S our population ages, a stronger interest in the issue of balance control has emerged. Previous research has shown that postural stability declines with age, and that these declines may be due to a multitude of factors that increase the likelihood of serious falls in many older adults. Included among these is an age-related deterioration in the

Feasibility and measurement properties of the functional reach and the timed up and go tests in the Canadian study of health and aging.

Abstract: BACKGROUND Physical performance measures may offer advantages over self-report in the functional assessment of older people. Estimates of the feasibility, reliability, and construct validity of these measures in large, heterogeneous samples are necessary to establish their importance relative to traditional measures of function. METHODS Analysis of clinical data from Phase 2 of the Canadian Study of Health and Aging, a nation-wide representative survey of elderly people in Canada (N = 2,305). RESULTS Both physical performance measures proved infeasible in many subjects (29.3% for the Timed Up and Go [TUG], 35.9% for the Functional Reach [FR]). Cognitive impairment was the most important determinant of inability to complete the tests. For those able to complete the tests, cognitively unimpaired subjects could reach farther (median 29 cm) and complete the TUG in less time (median 12 seconds) than those cognitively impaired (25 cm for FR, 15 seconds for the TUG). Test-retest reliability between the screening and clinical administrations of the TUG was .56 for all participants (intra-class correlations), .50 for the cognitively unimpaired, and .56 for the cognitively impaired. Construct validity was substantial, and correlations between performance measures and self-report activities of daily living (ADL) measures ranged from .40 to .70. Compared with a global clinical measure of frailty, correlations were more modest (.38 to .60). CONCLUSIONS The FR and the TUG were not feasible tools in this study. The TUG showed poor test-retest reliability. Our data support the observation that subsequent studies of measurement instruments typically reveal lower performance than the original reports.

Complementary and alternative medicine use among elderly persons: one-year analysis of a Blue Shield Medicare supplement.

Abstract: Background Large scale surveys in the United States and abroad suggest that 35-60% of adults have used some form of complementary/alternative medicine (CAM) However, no studies to date have focused on predictors and patterns of CAM use among elderly persons Methods The population surveyed were Californians enrolled in a Medicare risk product that offers coverage for acupuncture and chiropractic care Surveys were mailed to 1597 members in 1997 and responses received by 728 (51% response rate) Health risk assessment data were also obtained at baseline and 12-15 months following enrollment in the plan Multiple logistic regression analyses were carried out to examine predictors of CAM use Results Forty-one percent of seniors reported use of CAM Herbs (24%), chiropractic (20%), massage (15%), and acupuncture (14%) were the most frequently cited therapies CAM users tended to be younger, more educated, report either arthritis and/or depression/anxiety, not be hypertensive, engage in exercise, practice meditation, and make more frequent physician visits Use of CAM was not associated with any observed changes in health status Respondents also expressed considerable interest in receiving third-party coverage for CAM Although 80% reported that they had received substantial benefit from their use of CAM, the majority (58%) did not discuss the use of these therapies with their medical doctor Conclusions Findings suggest that there is significant interest in and use of complementary/alternative medicine among elderly persons These results suggest the importance of further research into the use and potential efficacy of these therapies within the senior population

Effects of Age, Gender, and Myostatin Genotype on the Hypertrophic Response to Heavy Resistance Strength Training

Abstract: BACKGROUND Because of the scarcity of data available from direct comparisons of age and gender groups using the same relative training stimulus, it is unknown whether older individuals can increase their muscle mass as much as young individuals and whether women can increase as much as men in response to strength training (ST). In addition, little is known about whether the hypertrophic response to ST is affected by myostatin genotype, a candidate gene for muscle hypertrophy. METHODS Eleven young men (25 +/- 3 years, range 21-29 years), 11 young women (26 +/- 2 years, range 23-28 years), 12 older men (69 +/- 3 years, range 65-75 years), and 11 older women (68 +/- 2 years, range 65-73 years) had bilateral quadriceps muscle volume measurements performed using magnetic resonance imaging (MRI) before and after ST and detraining. Training consisted of knee extension exercises of the dominant leg three times per week for 9 weeks. The contralateral limb was left untrained throughout the ST program. Following the unilateral training period, the subjects underwent 31 weeks of detraining during which no regular exercise was performed. Myostatin genotype was determined in a subgroup of 32 subjects, of which five female subjects were carriers of a myostatin gene variant. RESULTS A significantly greater absolute increase in muscle volume was observed in men than in women (204 +/- 20 vs 101 +/- 13 cm3, p < .01), but there was no significant difference in muscle volume response to ST between young and older individuals. The gender effect remained after adjusting for baseline muscle volume. In addition, there was a significantly greater loss of absolute muscle volume after 31 weeks of detraining in men than in women (151 +/- 13 vs 88 +/- 7 cm3, p < .05), but no significant difference between young and older individuals. Myostatin genotype did not explain the hypertrophic response to ST when all 32 subjects were assessed. However, when only women were analyzed, those with the less common myostatin allele exhibited a 68% larger increase in muscle volume in response to ST (p = .056). CONCLUSIONS Aging does not affect the muscle mass response to either ST or detraining, whereas gender does, as men increased their muscle volume about twice as much in response to ST as did women and experienced larger losses in response to detraining than women. Young men were the only group that maintained muscle volume adaptation after 31 weeks of detraining. Although myostatin genotype may not explain the observed gender difference in the hypertrophic response to ST, a role for myostatin genotype may be indicated in this regard for women, but future studies are needed with larger subject numbers in each genotype group to confirm this observation.

Effects of High-Intensity Resistance Training on Untrained Older Men. I. Strength, Cardiovascular, and Metabolic Responses

Abstract: Most resistance training studies of older subjects have emphasized low-intensity, short-term training programs that have concentrated on strength measurements. The purpose of this study was, in addition to the determination of strength, to assess intramuscular and transport factors that may be associated with strength increments. Eighteen untrained men ages 60-75 years volunteered for the study; 9 were randomly placed in the resistance-training group (RT), and the other half served as untrained (UT) or control subjects. RT subjects performed a 16-week high-intensity (85-90% 1 repetition maximum (RT]) resistance training program (2 x/wk) consisting of 3 sets each to failure (6-8 repetitions based on 1 RM of 3 exercises): leg press (LP), half squat (HS), and leg extension (LE) with 1-2 minutes rest between sets. Pre- and post- training strength was measured for the 3 training exercises using a 1 RM protocol. Body fat was calculated using a 3-site skinfold method. Biopsies from the vastus lateralis m. were obtained for fiber type composition, cross-sectional area, and capillarization measurements. Exercise metabolism, electrocardiography, and arterial blood pressure were observed continuously during a progressive treadmill test, and resting echocardiographic data were recorded for all subjects. Pre- and post-training venous blood samples were analyzed for serum lipids. Resistance training caused significant changes in the following comparisons: % fat decreased in the RT group by almost 3%, strength improved for all exercises: LE = + 50.4%, LP = + 72.3%, HS = + 83.5%; type IIB fibers decreased and IIA fibers increased; cross-sectional areas of all fiber types (I, IIA, IIB) increased significantly, and capillary to fiber ratio increased but not significantly. No differences were noted for ECG and echocardiographic data. The RT group significantly improved treadmill performance and VO2max. Pre- and post-training serum lipids improved but not significantly. No significant changes occurred in any pre- to post-tests for the UT group. The results show that skeletal muscle in older, untrained men will respond with significant strength gains accompanied by considerable increases in fiber size and capillary density. Maximal working capacity, VO2max, and serum lipid profiles also benefited from high-intensity resistance training, but no changes were observed for HR max, or maximal responses of arterial blood pressure. Older men may not only tolerate very high intensity work loads but will exhibit intramuscular, cardiovascular, and metabolic changes similar to younger subjects.

Basal concentrations and acute responses of serum hormones and strength development during heavy resistance training in middle-aged and elderly men and women.

Abstract: Effects of 6 months of heavy resistance training combined with explosive exercises on both basal concentrations and acute responses of total and free testosterone, growth hormone (GH), dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulfate (DHEAS), cortisol and sex hormone-binding globulin (SHBG), as well as voluntary neural activation and maximal strength of knee extensors were examined in 10 middle-aged men (M40; 42 +/- 2 years), 11 middle-aged women (W40; 39 +/- 3 years), 11 elderly men (M70; 72 +/- 3 years), and in 10 elderly women (W70; 67 +/- 3 years). The maximal integrated electromyographic (iEMG) and 1 repetition maximum (RM) knee-extension values remained unaltered in all groups during a 1-month control period with no strength training. During the 6-month training the 1RM values increased in M40 by 27 +/- 9% (p < .001), in M70 by 16 +/- 6% (p < .001), in W40 by 28 +/- 11% (p < .001), and in W70 by 24 +/- 10% (p < .001). The iEMGs of the vastus lateralis and medialis muscles increased(p < .05-.001) in M40, M70, W40, and W70. No systematic changes occurred during the experimental period in the mean concentrations of serum total and free testosterone, DHEA, DHEAS, GH, cortisol, or SHBG. However, the mean levels of individual serum free testosterone in W70 and serum testosterone in the total group of women correlated with the individual changes recorded in strength during the training (r = .55,p <.05; and r = .43,p <.05). The single exercise session both before and after the training resulted in significant responses in serum total and free testosterone concentrations in both male groups (p <.05-.01), but not in the female groups, as well as in serum GH levels in all groups (p <.05-.01) except W70 (ns). In summary, the present strength training led to great increases in maximal strength not only in middle-aged but also in elderly men and women. The strength gains were accompanied by large increases in the maximal voluntary activation of the trained muscles. None of the groups showed systematic changes in the mean serum concentrations of hormones examined. However, a low level of testosterone, especially in older women, may be a limiting factor in strength development and testosterone could mediate interactions with the nervous system contributing to strength development. The physiological significance of the lack of acute responsiveness of serum GH to heavy resistance exercise in older women for their trainability during prolonged strength training requires further examination.

Effects of Strength Training and Detraining on Muscle Quality Age and Gender Comparisons

Abstract: Maximal force production per unit of muscle mass (muscle quality, or MQ) has been used to describe the relative contribution of non-muscle-mass components to the changes in strength with age and strength training (ST). To compare the influence of age and gender on MQ response to ST and detraining, 11 young men (20-30 years), nine young women (20-30 years), 11 older men (65-75 years), and 11 older women (65-75 years), were assessed for quadriceps MQ at baseline, after 9 weeks of ST, and after 31 weeks of detraining. MQ was calculated by dividing quadriceps one repetition maximum (IRM) strength by quadriceps muscle volume determined by magnetic resonance imaging. All groups demonstrated significant increases in IRM strength and muscle volume after training (all p < .05). All groups also increased their MQ with training (all p < .01), but the gain in MQ was significantly greater in young women than in the other three groups (p < .05). After 31 weeks of detraining, MQ values remained significantly elevated above baseline levels in all groups (p < .05), except the older women. These results indicate that factors other than muscle mass contribute to strength gains with ST in young and older men and women, but those other factors may account for a higher portion of the strength gains in young women. These factors continue to maintain strength levels above baseline for up to 31 weeks after cessation of training in young men and women, and in older men.

Polypharmacy and Hospitalization Among Older Home Care Patients

Abstract: Methods. A retrospective chart review of 833 discharged older home care patients was performed. These patients were consecutive discharges from a single home care agency who either (a) returned to independent self-care or care of the family (S/F Care group) or (b) were admitted to the hospital (Hospitalized group). Medication assessment within these two groups included total number of medications (prescription and nonprescription); degree of polypharmacy (percentage of patients taking 5 or more, 7 or more, and 10 or more medications); and prevalence for different types of medications, including different types of inappropriate medications. Inappropriate medications were designated according to a list that was previously developed through a modified Delphi consensus technique by a panel of 13 experts in geriatric pharmacology and has been utilized in other studies. Student’s t test was used for continuous variables and chi-square test was used for categorical variables to evaluate for differences between the S/F Care group and the Hospitalized group ( p , .05). For comparisons of types of medications, p , .01 was used for significant differences, because of the high number of comparisons made. Results. Of 833 discharges, 644 (77.3%) returned to self-care or care of the Family (S/F Care group) and 189 (22.7%) were hospitalized. The Hospitalized group, compared with the S/F Care group, was taking a higher number of medications (mean 6 SD : 6.6 6 3.9 vs 5.7 6 3.4, p 5 .004), and had a higher percentage of patients taking 7 or more medications (46% vs 26%, p 5 .002) and 10 or more medications (21% vs 10%, p 5 .005), but not 5 or more medications. Only three types of medications were more commonly used among patients in the Hospitalized group than among patients in the S/F Care group: clonidine (4.2% vs 1.1%, p 5 .004); mineral supplements (23.8% vs 14.8%, p 5 .003); and metoclopramide (5.8% vs 2.0%, p 5 .006). The Hospitalized group had a lower percentage of patients taking inappropriate medications than did the S/F Care group (20% vs 27%, p 5 .040), but none of the types of inappropriate medications was used more often in either group. Conclusions. This study shows a relationship between high levels of polypharmacy and hospitalization. Although it cannot be determined from this study whether a higher number of medications was an indicator of sicker patients at risk for hospitalization, or whether a higher number of medications might have directly led to hospitalization, polypharmacy should still be considered a marker for older home care patients for whom prevention of hospitalization is the goal.

Delirium on Hospital Admission in Aged Hip Fracture Patients Prediction of Mortality and 2-Year Functional Outcomes

Abstract: Background. Hip fracture patients are at increased risk of confusion or delirium due to the trauma associated with the injury and the rapid progression to hospitalization and surgery, in addition to the pain and loss of function experienced. Hip fracture patients who develop delirium may require longer hospital stays, are more often discharged to longterm care, and have a generally poor prognosis for returning home or regaining function in activities of daily living (ADL). Methods. The present study examines the impact of delirium present on hospital admission in a sample of 682 nondemented, aged hip fracture patients residing in the community at the time of their fracture. In-hospital assessments designed to assess both prefracture and postfracture functioning, as well as follow-up interviews at 2, 6, 12, 18, and 24 months postfracture, were obtained from participants. Results. Analyses indicate that baseline or admission delirium is an important prognostic predictor of poor long-term outcomes in persons without known cognitive impairment, after controlling for age, gender, race, comorbidity, and functional status. Delirium at admission (i.e., prior to surgery) was associated with poorer functioning in physical, cognitive, and affective domains at 6 months postfracture and slower rates of recovery. Impairment and delays in recovery may be further exacerbated by increased depressive symptoms in confused patients over time. Delirium on hospital admission was not a significant predictor of mortality after adjustment for confounding factors. Conclusions. The present findings further emphasize the significance of immediate detection and treatment of delirium in hip fracture patients to ameliorate the short and long-term effects of acute confusion on functional outcomes. ELIRIUM is an acute confusional state that is common and serious in hospitalized older adults, with an estimated 10%‐56% of elderly patients experiencing this syndrome

Ubiquitous overexpression of CuZn superoxide dismutase does not extend life span in mice.

Abstract: Oxidative damage has been implicated in the aging process and in a number of degenerative diseases. To investigate the role of oxygen radicals in the aging process in mammals, the life spans of transgenic mice on a CD-1 background expressing increased levels of CuZn superoxide dismutase (CuZnSOD), the enzyme that metabolizes superoxide radicals, were determined. Homozygous transgenic mice with a two- to five-fold elevation of CuZnSOD in various tissues showed a slight reduction of life span, whereas hemizygous mice with a 1.5- to 3-fold increase of CuZnSOD showed no difference in life span from that of the nontransgenic littermate controls. The results suggest that constitutive and ubiquitous Overexpression of CuZnSOD alone is not sufficient to extend the life spans of transgenic mice.

Increase of Oxidatively Modified Protein Is Associated With a Decrease of Proteasome Activity and Content in Aging Epidermal Cells

Abstract: For the process of aging in epidermal cells to be characterized, the status of oxidized and damaged protein accumulation and removal by the proteasome has been investigated. Modified protein content and proteasome activity were assayed in lysates of epidermal cells from donors of different ages. Increased levels of oxidized proteins, glycated proteins, and proteins modified by the lipid peroxidation product 4-hydroxy-2-nonenal were observed in cells from old donors. At the same time, a decline of chymotrypsin-like and peptidylglutamyl-peptide hydrolase activities of the proteasome was found in aging keratinocytes. This age-related decline of the proteasome peptidase activities can be explained, at least in part, by a decreased proteasome content as observed by immunoblotting and enzyme-linked immunosorbent assay. In keratinocyte cultures, a decrease of proteasome activity and content was observed upon serial passaging. In cultures, as well as in skin, an inverse relationship was found between the aging marker 1-galactosidase and the proteasome content. These results suggest that proteasome is downregulated during replicative senescence as well as in aged cells in vivo, possibly resulting in the accumulation of modified proteins.

Nutritional Management in Long-Term Care Development of a Clinical Guideline

Abstract: Methods . The Council for Nutritional Clinical Strategies in Long-Term Care, an expert panel of interdisciplinary thought leaders representing academia and the medical community, derived a structured approach aimed at improving management of malnutrition in long-term care settings, using literature review and consensus development. The Clinical Guide to Prevent and Manage Malnutrition in Long-Term Care is based on a best-evidence approach to the management of nutritional problems in long-term care. Results. The Clinical Guide is divided into two parts, one designed for nursing staff, dietary staff, and dietitians, and a second directed to physicians, pharmacists, and dietitians. Conclusions. A structured approach to the management of unintended weight loss or malnutrition in long-term care is intended to ensure a comprehensive resident evaluation. While the Clinical Guide is presented in a linear fashion, many of the considerations can be done simultaneously and the order varied dependent on the individual resident’s needs. Further research to validate the effectiveness of using the algorithm in long-term care settings will be required.

Exploratory study of incident vehicle crashes among older drivers.

Abstract: BACKGROUND: As the number of older adult drivers increases, distinguishing safe from unsafe older adult drivers will become an increasing public health concern. We report on the medical and functional factors associated with vehicle crashes in a cohort of Alabama drivers, 55 years old and older. METHODS: This prospective study involved 174 older adults, on whom demographic, medical, functional, and physical performance data were collected in 1991. Subjects were then followed through 1996 for incident vehicle crashes. RESULTS: Sixty-one subjects experienced between one and four police-reported vehicle crashes during the study period. Following adjustment for age, race, days driven per week, and gender, Cox proportional-hazards models showed the following variables to be associated with crash involvement: reported difficulty with yardwork or light housework (relative risk [RR] = 2.1; 95% confidence interval [CI] 1.1, 4.0; p = .02), or opening ajar (RR = 3. 1; 95% CI 1.4, 6.7; p = .004); at least one crash before 1991 (RR = 2.1; 95% CI 1.2, 3.7; p = .008); using hypnotic medication (RR = 2.9; 95% CI 1.3, 6.6; p = .01); self-reported stroke or transient ischemic attack (RR = 2.7; 95% CI 1.1, 6.6; p = .03); scoring within the depressed range on the Geriatric Depression Scale (RR = 2.5; 95% CI 1.1, 6.0; p = .03), and failing the useful field-of-view test (RR = 1.9; 95% CI 1.0, 3.5; p = .05). CONCLUSIONS: Variables related to function, medication use, affect, neurological disease, and visuocognitive skills were associated with vehicle crash involvement in this cohort. Our findings suggest that multifactorial assessments are warranted to identify at-risk older drivers. Language: en

Comorbidity of five chronic health conditions in elderly community residents: determinants and impact on mortality.

Abstract: Background. Comorbidity is common in elderly persons. Its extent, correlates, and life-threatening impact in representative community residents are unclear. Methods. Self-reported information of physician-diagnosed coronary artery disease (CAD), cerebrovascular disease (CVD), diabetes, and cancer was obtained annually between 1986-87 and 1992-93, and hypertension was obtained triennially from the participants of the Duke Established Populations for Epidemiologic Studies of the Elderly, a stratified multistage sample of 4126 Black and White community residents aged 65-100, living in a five-county area of North Carolina. Date of death was obtained from death certificates identified through search of the National Death Index. Statistical procedures included descriptive statistics, logistic regression, and survival analysis. Results. Of this sample, 57% reported hypertension, 20% diabetes, 15% CAD, 9% cancer, and 9% CVD; 29% reported none of these conditions, whereas 29% reported two or more. Demographic characteristics were not related to Comorbidity with CVD or cancer. Increased education tended to be protective. The effect of age, gender, and race varied with condition. At baseline there was substantial Comorbidity among hypertension, CAD, CVD, and diabetes, but not with cancer. Hypertension, CVD, and diabetes were risk factors for CAD, whereas diabetes was a risk factor for CVD. After controlling for demographic characteristics, all health conditions except hypertension were predictive of 6-year mortality, as was the presence of Comorbidity. Conclusion. We found significant Comorbidity in older persons who have hypertension, CAD, CVD, or diabetes; particular risk of developing Comorbidity. particularly CAD, among those with hypertension, CVD, and diabetes; and risk of CVD in those with diabetes. With the exception of hypertension, these conditions, and Comorbidity per se, are life-threatening.