Showing papers in "Journals of Gerontology Series A-biological Sciences and Medical Sciences in 2001"
TL;DR: This study provides a potential standardized definition for frailty in community-dwelling older adults and offers concurrent and predictive validity for the definition, and finds that there is an intermediate stage identifying those at high risk of frailty.
Abstract: Background: Frailty is considered highly prevalent in old age and to confer high risk for falls, disability, hospitalization, and mortality. Frailty has been considered synonymous with disability, comorbidity, and other characteristics, but it is recognized that it may have a biologic basis and be a distinct clinical syndrome. A standardized definition has not yet been established.
Methods: To develop and operationalize a phenotype of frailty in older adults and assess concurrent and predictive validity, the study used data from the Cardiovascular Health Study. Participants were 5,317 men and women 65 years and older (4,735 from an original cohort recruited in 1989-90 and 582 from an African American cohort recruited in 1992-93). Both cohorts received almost identical baseline evaluations and 7 and 4 years of follow-up, respectively, with annual examinations and surveillance for outcomes including incident disease, hospitalization, falls, disability, and mortality.
Results: Frailty was defined as a clinical syndrome in which three or more of the following criteria were present: unintentional weight loss (10 lbs in past year), self-reported exhaustion, weakness (grip strength), slow walking speed, and low physical activity. The overall prevalence of frailty in this community-dwelling population was 6.9%; it increased with age and was greater in women than men. Four-year incidence was 7.2%. Frailty was associated with being African American, having lower education and income, poorer health, and having higher rates of comorbid chronic diseases and disability. There was overlap, but not concordance, in the cooccurrence of frailty, comorbidity, and disability. This frailty phenotype was independently predictive (over 3 years) of incident falls, worsening mobility or ADL disability, hospitalization, and death, with hazard ratios ranging from 1.82 to 4.46, unadjusted, and 1.29-2.24, adjusted for a number of health, disease, and social characteristics predictive of 5-year mortality. Intermediate frailty status, as indicated by the presence of one or two criteria, showed intermediate risk of these outcomes as well as increased risk of becoming frail over 3-4 years of follow-up (odds ratios for incident frailty = 4.51 unadjusted and 2.63 adjusted for covariates, compared to those with no frailty criteria at baseline).
Conclusions: This study provides a potential standardized definition for frailty in community-dwelling older adults and offers concurrent and predictive validity for the definition. It also finds that there is an intermediate stage identifying those at high risk of frailty. Finally, it provides evidence that frailty is not synonymous with either comorbidity or disability, but comorbidity is an etiologic risk factor for, and disability is an outcome of, frailty. This provides a potential basis for clinical assessment for those who are frail or at risk, and for future research to develop interventions for frailty based on a standardized ascertainment of frailty.
16,255 citations
Journal Article•
11,919 citations
TL;DR: The Mini-Nutritional Assessment can identify persons with undernutrition and can be used in a two-step screening process in which persons, identified as "at risk" on the MNA-SF, would receive additional assessment to confirm the diagnosis and plan interventions.
Abstract: Background The Mini-Nutritional Assessment (MNA) is a validated assessment instrument for nutritional problems, but its length limits its usefulness for screening. We sought to develop a screening version of this instrument, the MNA-SF, that retains good diagnostic accuracy. Methods We reanalyzed data from France that were used to develop the original MNA and combined these with data collected in Spain and New MEXICO: Of the 881 subjects with complete MNA data, 151 were from France, 400 were from Spain, and 330 were from New MEXICO: Independent ratings of clinical nutritional status were available for 142 of the French subjects. Overall, 73.8% were community dwelling, and mean age was 76.4 years. Items were chosen for the MNA-SF on the basis of item correlation with the total MNA score and with clinical nutritional status, internal consistency, reliability, completeness, and ease of administration. Results After testing multiple versions, we identified an optimal six-item MNA-SF total score ranging from 0 to 14. The cut-point score for MNA-SF was calculated using clinical nutritional status as the gold standard (n = 142) and using the total MNA score (n = 881). The MNA-SF was strongly correlated with the total MNA score (r = .945). Using an MNA-SF score of > or = 11 as normal, sensitivity was 97.9%, specificity was 100%, and diagnostic accuracy was 98.7% for predicting undernutrition. Conclusions The MNA-SF can identify persons with undernutrition and can be used in a two-step screening process in which persons, identified as "at risk" on the MNA-SF, would receive additional assessment to confirm the diagnosis and plan interventions.
1,781 citations
Journal Article•
1,071 citations
TL;DR: Although muscle mass changes influenced the magnitude of the strength changes over time, strength declines in spite of muscle mass maintenance or even gain emphasize the need to explore the contribution of other cellular, neural, or metabolic mediators of strength changes.
Abstract: The longitudinal changes in isokinetic strength of knee and elbow extensors and flexors, muscle mass, physical activity, and health were examined in 120 subjects initially 46 to 78 years old. Sixty-eight women and 52 men were reexamined after 9.7 +/- 1.1 years. The rates of decline in isokinetic strength averaged 14% per decade for knee extensors and 16% per decade for knee flexors in men and women. Women demonstrated slower rates of decline in elbow extensors and flexors (2% per decade) than men (12% per decade). Older subjects demonstrated a greater rate of decline in strength. In men, longitudinal rates of decline of leg muscle strength were approximately 60% greater than estimates from a cross-sectional analysis in the same population. The change in leg strength was directly related to the change in muscle mass in both men and women, and it was inversely related to the change in medication use in men. Physical activity declined yet was not directly associated with strength changes. Although muscle mass changes influenced the magnitude of the strength changes over time, strength declines in spite of muscle mass maintenance or even gain emphasize the need to explore the contribution of other cellular, neural, or metabolic mediators of strength changes.
867 citations
TL;DR: This article critically reviews the literature on physical activity and quality of life in older adults and attention is given to both quality ofLife as a psychological construct represented by life satisfaction as well as a clinical and geriatric outcome represented by the core dimensions of health status or health-related quality oflife.
Abstract: Although there has been increased research and clinical attention given to the effects that physical activity has on quality of life among older adults, there is a lack of consistency surrounding the use of this term. As a result, attempts to examine what causes change in quality of life have been limited. This article critically reviews the literature on physical activity and quality of life in older adults. In so doing, attention is given to both quality of life as a psychological construct represented by life satisfaction as well as a clinical and geriatric outcome represented by the core dimensions of health status or health-related quality of life. The literature is also examined to identify potential mediators and moderators in the physical activity and quality-of-life relationship. Discussion of possible mediating variables reinforces the important role of perception when considering the beneficial effects that physical activity has on quality of life. From a public health perspective, understanding what may cause change in quality of life has significant implications for the design, implementation, and promotion of physical activity programs for older adults.
800 citations
TL;DR: Cardiovascular disease was associated with an increased likelihood of frail health and infarct-like lesions in the brain on magnet resonance imaging were related to frailty as well.
Abstract: Methods. Frailty status was defined in participants of the Cardiovascular Health Study (CHS), a cohort of 5,201 community-dwelling older adults, based on the presence of three out of five clinical criteria. The five criteria included selfreported weight loss, low grip strength, low energy, slow gait speed, and low physical activity. We examined the spectrum of clinical and subclinical cardiovascular disease in those who were frail (3/5 criteria) or of intermediate frailty status (1or 2/5 criteria), compared to those who were not frail (0/5). We hypothesized that the severity of frailty would be related to a higher prevalence of reported cardiovascular disease (CVD), as well as to a greater extent of CVD, measured by noninvasive testing. Results. Of 4,735 eligible participants, 2,289 (48%) were not frail, 299 (6%) were frail, and 2,147 (45%) were of intermediate frailty status. Those who were frail were older (77.2 yrs) compared to those who were not frail (71.5 yrs) or intermediate (73.4 yrs) ( p , .001). Frailty status was associated with clinical CVD and most strongly with congestive heart failure (odds ratio [OR] 5 7.51 (95% confidence interval [CI] 5 4.66‐12.12). In those without a history of a CVD event ( n 5 1,259), frailty was associated with many noninvasive measures of CVD. Those with carotid stenosis . 75% (adjusted OR 5 3.41), ankle-arm index , 0.8 (adjusted OR 5 3.17) or 0.8‐0.9 (adjusted OR 5 2.01), major electrocardiography (ECG) abnormalities (adjusted OR 5 1.58), greater left ventricular (LV) mass by echocardiography (adjusted OR 5 1.16), and higher degree of infarct-like lesions in the brain (adjusted OR 5 1.71), were more likely to be frail compared to those who were not frail. The overall associations of each of these noninvasive measures of CVD with frailty level were significant (all p , .05). Conclusions. Cardiovascular disease was associated with an increased likelihood of frail health. In those with no history of CVD, the extent of underlying cardiovascular disease measured by carotid ultrasound and ankle‐arm index, LV hypertrophy by ECG and echocardiography, was related to frailty. Infarct-like lesions in the brain on magnet resonance imaging were related to frailty as well.
724 citations
TL;DR: Public policy should focus on ways of increasing volitional and lifestyle activity in older people, as well as on increasing the availability and accessibility of senior and community center programs for promoting physical activity throughout the life span.
Abstract: Sedentary behavior is an important risk factor for chronic disease morbidity and mortality in aging. However, there is a limited amount of information on the type and amount of activity needed to promote optimal health and function in older people. The purpose of this review is to describe the change in patterns of habitual physical activity in aging and the relationship of these changes to physical function and selected chronic diseases. We undertook a literature review of large population-based studies of physical activity in older people, and there is encouraging evidence that moderate levels of physical activity may provide protection from certain chronic diseases. Additionally, substantial health effects can be accrued independent of the fitness effects achieved through sustained vigorous activity. Thus, regular participation (i.e., 30 minutes/day on most days of the week) in activities of moderate intensity (such as walking, climbing stairs, biking, or yardwork/gardening), which increase accumulated daily energy expenditure and maintain muscular strength, but may not be of sufficient intensity for improving fitness, should be encouraged in older adults. Public policy should focus on ways of increasing volitional and lifestyle activity in older people, as well as on increasing the availability and accessibility of senior and community center programs for promoting physical activity throughout the life span.
552 citations
TL;DR: In this paper, a systematic literature search, 21 articles published from 1984 through 2000 describing 20 fall risk assessments were reviewed independently for content and validation by a panel of five reviewers using a standardized review form.
Abstract: Background Clinicians are often unaware of the many existing scales for identifying fall risk and are uncertain about how to select an appropriate one. Our purpose was to summarize existing fall risk assessment scales to enable more informed choices regarding their use. Methods After a systematic literature search, 21 articles published from 1984 through 2000 describing 20 fall risk assessments were reviewed independently for content and validation by a panel of five reviewers using a standardized review form. Fourteen were institution-focused nursing assessment scales, and six were functional assessment scales. Results The majority of the scales were developed for elderly populations, mainly in hospital or nursing home settings. The patient characteristics assessed were quite similar across the nursing assessment forms. The time to complete the form varied from less than 1 minute to 80 minutes. For those scales with reported diagnostic accuracy, sensitivity varied from 43% to 100% (median = 80%), and specificity varied from 38% to 96% (median = 75%). Several scales with superior diagnostic characteristics were identified. Conclusions A substantial number of fall risk assessment tools are readily available and assess similar patient characteristics. Although their diagnostic accuracy and overall usefulness showed wide variability, there are several scales that can be used with confidence as part of an effective falls prevention program. Consequently, there should be little need for facilities to develop their own scales. To continue to develop fall risk assessments unique to individual facilities may be counterproductive because scores will not be comparable across facilities.
474 citations
TL;DR: Transdermal testosterone (5 mg/d) prevented bone loss at the femoral neck, decreased body fat, and increased lean body mass in a group of healthy men over age 65 with low bioavailable testosterone levels, and demonstrated gains in lower extremity muscle strength.
Abstract: Background. A large proportion of men over 65 years of age have bioavailable testosterone levels below the reference range of young adult men. The impact of this on musculoskeletal health and the potential for improvement in function in this group with testosterone supplementation require investigation. Methods. Sixty-seven men (mean age 76 6 4 years, range 65‐87) with bioavailable testosterone levels below 4.44 nmol/l (lower limit for adult normal range) were randomized to receive transdermal testosterone (two 2.5-mg patches per day) or placebo patches for 1 year. All men received 500 mg supplemental calcium and 400 IU vitamin D. Outcome measures included sex hormones (testosterone, bioavailable testosterone, sex-hormone binding globulin [SHBG], estradiol, and estrone), bone mineral density (BMD; femoral neck, Ward’s triangle, trochanter, lumbar spine, and total body), bone turnover markers, lower extremity muscle strength, percent body fat, lean body mass, hemoglobin, hematocrit, prostate symptoms, and prostate specific antigen (PSA) levels. Results. Twenty-three men (34%) withdrew from the study; 44 men completed the trial. In these men, bioavailable testosterone levels increased from 3.2 6 1.2 nmol/l ( SD ) to 5.6 6 3.5 nmol/l ( p , .002) at 12 months in the testosterone group, whereas no change occurred in the control group. Although there was no change in estradiol levels in either group, estrone levels increased in the testosterone group (103 6 26 pmol/l to 117 6 33 pmol/l; p , .017). The testosterone group had a 0.3% gain in femoral neck BMD, whereas the control group lost 1.6% over 12 months ( p 5 .015). No significant changes were seen in markers of bone turnover in either group. Improvements in muscle strength were seen in both groups at 12 months compared with baseline scores. Strength increased 38% ( p 5 .017) in the testosterone group and 27% in the control group ( p 5 .06), with no statistical difference between the groups. In the testosterone group, body fat decreased from 26.3 6 5.8% to 24.6 6 6.5% ( p 5 .001), and lean body mass increased from 56.2 6 5.3 kg to 57.2 6 5.1 kg ( p 5 .001), whereas body mass did not change. Men receiving testosterone had an increase in PSA from 2.0 6 1.4 m g/l to 2.6 6 1.8 m g/l ( p 5 .04), whereas men receiving placebo had an increase in PSA from 1.9 6 1.0 m g/l to 2.2 6 1.5 m g/l ( p 5 .09). No significant differences between groups were seen in hemoglobin, hematocrit, symptoms or signs of benign prostate hyperplasia, or PSA levels. Conclusions. Transdermal testosterone (5 mg/d) prevented bone loss at the femoral neck, decreased body fat, and increased lean body mass in a group of healthy men over age 65 with low bioavailable testosterone levels. In addition, both testosterone and placebo groups demonstrated gains in lower extremity muscle strength, possibly due to the beneficial effects of vitamin D. Testosterone did result in a modest increase in PSA levels but resulted in no change in signs or symptoms of prostate hyperplasia.
451 citations
TL;DR: Well-functioning persons in their 70s exhibit a broad range of functional capacity readily ascertained by expanded self-report and performance tests, and weak correlations indicate they tap different, but important, dimensions of physical function.
Abstract: Results. The expanded self-report items identified one half of the men and one third of the women as exceptionally well functioning and 10% to 13% of men and 21% to 36% of women with lower capacity. The supplemented and rescored performance battery discriminated function over the full range. The LDCW further differentiated walking capacity at the high end and also identified a subgroup with limitations. The self-report and performance measures were significantly, but weakly, correlated (0.13‐0.35) and were independent predictors of walking endurance. Conclusions. Well-functioning persons in their 70s exhibit a broad range of functional capacity readily ascertained by expanded self-report and performance tests. Significant associations among these measures support their concurrent validity, but generally weak correlations indicate they tap different, but important, dimensions of physical function.
TL;DR: A decline in adaptive relaxation of the fundus of the stomach and an increased rate of antral filling appear to play a role in the early satiation seen in many older persons.
Abstract: There is a physiological decline in food intake with aging. The reasons for the decline in food intake are multifactorial and involve both peripheral and central mechanisms. Altered hedonic qualities of food occur due to alterations in taste and, more particularly, smell with aging. A decline in adaptive relaxation of the fundus of the stomach and an increased rate of antral filling appear to play a role in the early satiation seen in many older persons. Cholecystokinin levels are increased with aging and older persons are more sensitive to the satiating effects of this gut hormone. The decline in testosterone levels in older males leads to increased leptin levels and this may explain the greater decline in food intake with aging in the male. Within the hypothalamus, decreased activity of both the dynorphin (kappa opioid) and neuropeptide Y systems occurs in aging rodents. Cytokines are potent anorectic agents. Many older persons have mild inflammatory disorders that lead to anorexia. Exercise may increase food intake in older persons.
TL;DR: The maintenance of whole-body leucine metabolism and whole- body composition is generally consistent with a successful adaptation to the RDA for protein, however, the decrease in mid-thigh muscle area and the association with decreased urinary nitrogen excretion are consistent withA metabolic accommodation.
Abstract: Background Inadequate dietary protein intake results in loss of skeletal muscle mass. Some shorter-term nitrogen balance studies suggest that the Recommended Dietary Allowance (RDA) of protein may not be adequate for older people. The aim of this study was to assess the adequacy of the RDA of protein for older people by examining longer-term responses in urinary nitrogen excretion, whole-body protein metabolism, whole-body composition, and mid-thigh muscle area. Methods This was a 14-week precisely controlled diet study. Ten healthy, ambulatory men and women, aged 55 to 77 years, were provided eucaloric diets that contained 0.8 g protein.kg(-1).day(-1). The study was conducted at a General Clinical Research Center using an outpatient setting for 11 weeks and an inpatient setting for 3 weeks. The main outcome measures included urinary nitrogen excretion, postabsorptive and postprandial whole-body leucine kinetics via infusion of L-[1-(13)C]-leucine, whole-body density via hydrostatic weighing, total body water via deuterium oxide dilution, and mid-thigh muscle area via computed tomography scans. Results Mean urinary nitrogen excretion decreased over time from Weeks 2 to 8 to 14 (p =.025). At Week 14, compared with Week 2, there were no changes in postabsorptive or postprandial leucine kinetics (turnover, oxidation, incorporation into protein via synthesis, release via breakdown, or balance). Whole-body composition (% body fat, fat-free mass, and protein + mineral mass) did not change over time in these weight-stable subjects. Mid-thigh muscle area was decreased by -1.7 +/- 0.6 cm(2) (p =.019) at Week 14 compared with Week 2. The loss of mid-thigh muscle area was associated with the decrease in urinary nitrogen excretion (Spearman r =.83, p =.010). Conclusions The maintenance of whole-body leucine metabolism and whole-body composition is generally consistent with a successful adaptation to the RDA for protein. However, the decrease in mid-thigh muscle area and the association with decreased urinary nitrogen excretion are consistent with a metabolic accommodation. These results suggest that the RDA for protein may not be adequate to completely meet the metabolic and physiological needs of virtually all older people.
TL;DR: Major issues currently facing the field are discussed, including the ongoing challenge of developing assessment tools that are sensitive to the more moderate-intensity physical activities favored by older adults and the formidable task of combining clinical approaches with environmental and policy strategies aimed at combating this public health problem.
Abstract: Physical inactivity has been established to be an independent risk factor for a range of chronic diseases and conditions that threaten the health of the nation. However, only a minority of the population is currently meeting the recommended levels of regular physical activity, which have been linked with important health and quality-of-life benefits. Older adults are at particular risk for leading sedentary lifestyles. This article provides an overview of factors associated with physical activity for older adults and also describes potentially promising interventions for promoting regular physical activity in this growing population segment. Examples of interventions undertaken at personal and interpersonal as well as broader levels of analysis (e.g., environmental) are provided. Major issues currently facing the field are discussed, including the ongoing challenge of developing assessment tools that are sensitive to the more moderate-intensity physical activities favored by older adults and the formidable task of combining clinical approaches with environmental and policy strategies aimed at combating this public health problem.
TL;DR: These important articles provide a link between diet and exercise and quality-of-life issues, as outlined in the Healthy People 2010 report.
Abstract: If health-related quality of life--and not longevity--is the key goal for health promotion, then it is captured only partly by the existing mortality and morbidity indexes. Researchers now urge that government agencies and health care providers begin collecting quality-of-life data on the populations they serve. Adding life to years, not years to life, is the current agenda for productive and successful aging. Policies and programs on aging are increasingly focused on identifying ways to improve quality of life and health status rather than just extending life span. In the Healthy People 2000 report, the chief goal of health promotion was to increase the span of healthy life. The focus was on mortality and morbidity data and symptom checklists as the principal measures of ill health. In contrast, the new emphasis in the Healthy People 2010 report is on quality of life and overall well-being. Helping people to increase life expectancy and improve their quality of life is the primary goal of the Healthy People 2010 report. The authors of this special issue of the Journals of Gerontology: Biological Sciences and Medical Sciences are united in the belief that optimal nutrition and physical activity make a significant contribution to the overall quality of life at any age and especially for older adults. The key research challenge lies in deciding which aspects of improved fitness, nutrition, and diet contribute the most to quality-of-life measures. We have attempted to provide a comprehensive review of research on exercise, nutrition, diet, and health in elderly adults. Past studies on diet, nutrition, and fitness have largely addressed biomedical outcomes, pointing to substantial benefits in physical functioning, remission of disease symptoms, and improved health. This special issue goes a step further in assessing the effect of improved nutrition and physical activity on the global quality of life and its four principal domains. Although links between diet and exercise and chronic disease risks have been well documented, more needs to be known about motivations for behavioral change and perceived benefits as assessed using quality-of-life measures. No single segment of our society can benefit more from regularly performed exercise and improved diet than elderly adults. These important articles provide a link between diet and exercise and quality-of-life issues, as outlined in the Healthy People 2010 report.
TL;DR: A new test of choice stepping reaction time (CSRT) is identified that provides a composite measure of falls risk in older people and elucidates the relative importance of specific physiological and neuropsychological systems in the initiation of fast and appropriate step responses.
Abstract: 2� .45). Subjects with a history of falls had significantly increased CSRTs compared with nonfallers (1322 � 331 milliseconds and 1168 � 203 milliseconds, respectively). Impaired CSRT was a significant and independent predictor of falls, as were two complementary sensory measures (visual contrast sensitivity and lower limb proprioception). Of these measures, CSRT was the most important in predicting falls. Furthermore, the inclusion of CSRT in the model excluded measures of strength, central processing speed, and balance, because these could not provide nonredundant information for the prediction of falls. Conclusions. This study identifies a new test that provides a composite measure of falls risk in older people and elucidates the relative importance of specific physiological and neuropsychological systems in the initiation of fast and appropriate step responses.
TL;DR: With the aging of the population, more research is needed on nutrient requirements and health outcomes, and public health efforts are needed to increase physical activity and food intake among older people.
Abstract: Cohort and cross-sectional data were reviewed to describe the changes in dietary intake with age. Total energy intake decreases varied substantially with age, by 1000 to 1200 kcal in men and by 600 to 800 kcal in women. This resulted in concomitant declines in most nutrient intakes. For some nutrients, substantial numbers of older Americans consumed only one fifth to one third of the recommended dietary allowance. For most nutrients, research is lacking with which to judge the health impact of reduced nutrient consumption with age, although there is some evidence of an age-related decline in absorptive and metabolic function. With the aging of the population, more research is needed on nutrient requirements and health outcomes, and public health efforts are needed to increase physical activity and food intake among older people.
TL;DR: Unsupervised weight-lifting exercise maintains its antidepressant effectiveness at 20 weeks in depressed elderly patients, suggesting long-term changes in exercise behavior are possible in some patients even without supervision.
Abstract: Background . Pharmacological treatment of depression in geriatric patients is often difficult. Although unsupervised exercise has been shown to benefit younger depressed patients, there is no evidence that unsupervised exercise can be used as a maintenance treatment for depression in elderly patients. Our aim was to test the feasibility and efficacy of un- supervised exercise as a long-term treatment for clinical depression in elderly patients. Methods. We studied 32 subjects (71.3 � 1.2 years of age, meanSE ) in a 20-week, randomized, controlled trial, with follow-up at 26 months. Subjects were community-dwelling patients with major or minor depression or dysthymia. Exercisers engaged in 10 weeks of supervised weight-lifting exercise followed by 10 weeks of unsupervised exercise. Controls attended lectures for 10 weeks. No contact was made with either group after 20 weeks until final follow-up. Blinded assessment was made with the Beck Depression Inventory (BDI), the Philadelphia Geriatric Morale Scale, and Ewart's Self Efficacy Scale at 20 weeks and with the BDI and physical activity questionnaire at 26 months. Results. Patients randomized to the exercise condition completed 18 � 2 sessions of unsupervised exercise during Weeks 10 to 20. The BDI was significantly reduced at both 20 weeks and 26 months of follow-up in exercisers com- pared with controls ( p � .05-.001). At the 26-month follow-up, 33% of the exercisers were still regularly weight lifting, versus 0% of controls ( p � .05). Conclusions. Unsupervised weight-lifting exercise maintains its antidepressant effectiveness at 20 weeks in de- pressed elderly patients. Long-term changes in exercise behavior are possible in some patients even without supervision.
TL;DR: Accurate measurement of trunk angular sway during stance and gait tasks provides a simple way of reliably measuring changes in balance stability with age and could prove useful when screening for balance disorders of those prone to fall.
Abstract: BACKGROUND The major disadvantage of current clinical tests that screen for balance disorders is a reliance on an examiner's subjective assessment of equilibrium control. To overcome this disadvantage we investigated, using quantified measures of trunk sway, age-related differences of normal subjects for commonly used clinical balance tests. METHODS Three age groups were tested: young (15-25 years; n = 48), middle-aged (45-55 years; n = 50) and elderly (65-75 years; n = 49). Each subject performed a series of fourteen tasks similar to those included in the Tinetti and Clinical Test of Sensory Interaction in Balance protocols. The test battery comprised stance and gait tasks performed under normal, altered visual (eyes closed), and altered proprioceptive (foam support surface) conditions. Quantification of trunk sway was performed using a system that measured trunk angular velocity and position in the roll (lateral) and pitch (fore-aft) planes at the level of the lower back. Ranges of sway amplitude and velocity were examined for age-differences with ANOVA techniques. RESULTS A comparison between age groups showed several differences. Elderly subjects were distinguished from both middle-aged and young subjects by the range of trunk angular sway and angular velocity because both were greater in roll and pitch planes for stance and stance-related tasks (tandem walking). The most significant age group differences (F = 30, p <.0001) were found for standing on one leg on a normal floor or on a foam support surface with eyes open. Next in significance was walking eight tandem steps on a normal floor (F = 13, p <.0001). For gait tasks, such as walking five steps while rotating or pitching the head or with eyes closed, pitch and roll velocity ranges were influenced by age with middle-aged subjects showing the smallest ranges followed by elderly subjects and then young subjects (F = 12, p <.0001). Walking over a set of low barriers also yielded significant differences between age groups for duration and angular sway. In contrast, task duration was the only variable significantly influenced when walking up and down a set of stairs. An interesting finding for all tasks was the different spread of values for each population. Population distributions were skewed for all ages and broadened with age. CONCLUSIONS Accurate measurement of trunk angular sway during stance and gait tasks provides a simple way of reliably measuring changes in balance stability with age and could prove useful when screening for balance disorders of those prone to fall.
TL;DR: This is the first prospective study using a large representative cohort of elderly persons to demonstrate that progressive cognitive decline is associated with a specific pattern of loss of functional tasks, and a natural hierarchy of functional loss associated with cognitive decline emerged.
Abstract: Objectives We studied a representative cohort of community-dwelling elderly persons to (i) examine the relationship between the loss of specific functional activities and cognitive status at the time of these losses, (ii) compare the cognitive status of participants who have and have not lost independence in these functional activities, and (iii) determine whether a hierarchical scale of functional loss is associated with declining cognitive status. Methods A cohort of 5874 community-dwelling persons aged 65 years and older from the Canadian Study of Health and Aging I and II were analyzed. At baseline and 5 years later, cognitive status with the Modified Mini-Mental State Examination (3MS) and functional status with 14 Older American Resources and Services (OARS) items were measured. For each OARS functional item, the mean 3MS scores for persons who lost independence during the 5-year period versus those who did not were compared. Results For each functional item, the 5-year decline in 3MS scores of persons who lost independence were significantly greater than those who remained independent (e.g., ability to do finances), with an 18-point decline for those who lost independence and a 2-point decline for those who retained independence. A hierarchy of functional items existed, with instrumental activities of daily living (ADLs) (e.g., shopping, banking, and cooking) being lost at higher cognitive scores than basic ADL items (e.g., eating, dressing, and walking), although there was some overlap. Conclusions This is the first prospective study using a large representative cohort of elderly persons to demonstrate that progressive cognitive decline is associated with a specific pattern of loss of functional tasks. Clear cognitive thresholds at which development of dependency in OARS functional items occurred. By providing estimates of the cognitive status of persons at the time at which they developed dependency in specific functional items, a natural hierarchy of functional loss associated with cognitive decline emerged. For caregivers, clinicians, and health policy makers, this information can help anticipate the pattern of functional decline and the subsequent care needs of persons with declining cognition, potentially improving the quality of life of these persons and their caregivers and playing an important part in health care planning.
TL;DR: It is suggested that strength training alone does not appear to enhance standing balance or sit-to-stand performance in active, community-dwelling older adults but that it may improve maximal walking speed.
Abstract: Background. Muscle size and strength decrease with aging, and the resultant muscle weakness has been implicated in increased risk of falls in older adults. These falls have large economic and functional costs. Methods. The purpose of this randomized, controlled study was to determine if an 8-week, 3-day per week intense (77.8 6 3.4% of 1-repetition maximum [1RM]) strength training program could improve functional ability related to the risk of falling in subjects aged 61—87 years (mean 72, SD 6.3). Twelve strength-training‐naive subjects performed two sets of 10 repetitions for six lower body exercises while 12 subjects served as nonintervention controls. Subjects were tested pre-, mid-, and postintervention for strength gain and on three tests of functional ability.
TL;DR: Walking quickly may be the greatest cause of falling following a trip in healthy older adults, and an anterior body mass carriage, accompanied by back and knee extensor weakness, may also lead to falls following a trips.
Abstract: BACKGROUND Tripping is a leading cause of falls in older adults, often resulting in serious injury. Although the requirements for recovery from a trip are well characterized, the mechanisms whereby trips by older adults actually result in falls are not known. This study sought to identify such mechanisms. METHODS Trips were induced during gait in 79 healthy, community-dwelling, safety-harnessed, older adults (50 women) using a concealed, mechanical obstacle. Kinematic and kinetic variables describing the recovery attempts were compared between those who fell and those who recovered. Subjects were analyzed according to the recovery strategy employed (lowering vs elevating) and the time of the "fall" (during step vs after step). RESULTS Three apparent mechanisms of falling were identified. For a lowering strategy, during-step falls were associated with a faster walking speed at the time of the trip (91% +/- 8% vs 68% +/- 11% body height [bh] per second; p <.001) and delayed support limb loading (267 +/- 49 milliseconds vs 160 +/- 39 milliseconds; p <.001). After-step falls were associated with a more anterior head-arms-torso center of mass at the time of the trip (6.2 +/- 1.3 degrees vs 0.2 +/- 4.4 degrees; p <.01), followed by excessive lumbar flexion and buckling of the recovery limb. The elevating strategy fall was associated with a faster walking speed (93% vs 68% +/- 11% bh per second; p <.001) followed by excessive lumbar flexion. CONCLUSIONS Walking quickly may be the greatest cause of falling following a trip in healthy older adults. An anterior body mass carriage, accompanied by back and knee extensor weakness, may also lead to falls following a trip. Deficient stepping responses did not contribute to the falls.
TL;DR: Existing scientific evidence does not support a strong argument for late-life exercise as an effective means of reducing disability, and the theoretical basis of interventions aimed at reducing disability may need to extend beyond exercise and address behavioral and social factors.
Abstract: Background Increasing exercise among older adults to improve function and prevent or decrease disability is widely promoted in developed countries. This review seeks to critically evaluate the degree to which existing scientific evidence supports these claims. Methods A literature review was performed in Medline and Best Evidence databases for the years 1985 to 2000. Experimental and quasi-experimental aerobic and resistance exercise interventions were reviewed for impairment, function, and disability outcomes. The impact of exercise on specific impairments, functions, and disabilities was examined by summarizing the findings reported across all studies. Results Thirty-one studies were identified. Impairment and functional outcomes were reported in 97% and 81% of the studies, respectively; half of the studies examined disability outcomes. The most consistent positive effects of late-life exercise were observed in strength, aerobic capacity, flexibility, walking, and standing balance, with over half of the studies that examined these outcomes finding positive effects. Of the studies that examined physical, social, emotional, or overall disability outcomes, most found no improvements. In the five studies that reported reduced physical disability, the effect sizes ranged from .23 to .88. Conclusions Late-life exercise clearly improves strength, aerobic capacity, flexibility, and physical function. Existing scientific evidence, however, does not support a strong argument for late-life exercise as an effective means of reducing disability. This may be due, in part, to methodological limitations in studies that have examined disability outcomes. On the other hand, the theoretical basis of interventions aimed at reducing disability may need to extend beyond exercise and address behavioral and social factors.
TL;DR: Connections between diet and nutritional status in relation to HRQOL measures and overall well-being among older adults are explored.
Abstract: Good nutrition promotes health-related quality of life (HRQOL) by averting malnutrition, preventing dietary deficiency disease and promoting optimal functioning. However, definitions of quality of life also encompass life satisfaction and both physical and mental well-being. Nutrition and diet have not been a part of mainstream research on quality of life and are not included among key quality of life domains. This article explores connections between diet and nutritional status in relation to HRQOL measures and overall well-being among older adults.
TL;DR: The effectiveness of CHAMPS II, an inclusive, choice-based physical activity promotion program to increase lifetime physical activity levels of seniors, is examined to find individually tailored programs to encourage lifestyle changes in seniors may be effective and applicable to health care and community settings.
Abstract: THE increasing burden of health problems and health care costs of our burgeoning older population requires more preventive approaches. Regular physical activity is a prominent strategy, based on a large body of evidence that it contributes substantially to the health, functioning, and quality of life of older adults (1–3). Physical activity may also be associated with less frequent utilization of health services (4–7).
One is never too old to derive benefits from regular physical activity. Indeed, those who are sedentary or weak often gain the most health benefit by becoming more active (8–10). Further, moderate-intensity physical activity is beneficial (11,12) and easier for older adults to adhere to than vigorous activity (13).
Most older adults, however, remain significantly underactive (2). Only about 25% of men and 20% of women aged 65 years and older meet the national guidelines for regular physical activity (2). In three national data sets, among those aged 65 to 74, 28% to 37% of women and 18% to 33% of men reported no participation (2). Among those aged 75 and older, 38% to 54% of women and 27% to 38% of men reported no participation in any leisure time physical activity.
A critical next step is to implement practical and inclusive community-based programs to increase the physical activity levels of sedentary and underactive older adults. Most physical activity studies of older adults focus on examining health or fitness outcomes of various physical activity prescriptions or protocols, with physical activity as the independent variable. Very few have been designed specifically to change the lifestyle of older adults, that is, to help participants make regular physical activity and/or exercise a routine part of their lives (14). In such studies, the independent variable is whether or not they received a program of support for lifestyle changes (15). Participants in such programs choose the activity or set of activities they would like to do (with guidance) and set their own goals for increasing activity. This feature of choice enables individual preferences, which vary among older adults (16,17), to be taken into account, as well as readiness to change (18).
This article examines the effectiveness of the Community Healthy Activities Model Program for Seniors (CHAMPS II) a lifestyle program based on the personal choice model that promotes increased physical activity levels. We evaluate the physical activity outcomes of this program using a randomized design and determine whether the program worked equally well for subgroups likely to have more difficulty changing their physical activity behavior (e.g., completely sedentary, overweight participants).
TL;DR: The ability to recover balance using a feet-in-place response was more attentionally demanding in balance-impaired than in healthy elderly persons and dual-task performance may contribute to postural instability and falls in Balance-IMpaired elderly individuals.
Abstract: Background. Although postural recovery is attentionally demanding in healthy elderly persons, an inability to recover balance due to competition for attentional resources between the postural system and a second task could contribute to falls in older adults with poor balance. This study examined the attentional demands of balance recovery from a mild postural disturbance in balance-impaired elderly persons. A second purpose of this research was to determine the effect of performing a cognitive task on the recovery of balance in balance-impaired elderly persons. Methods. Fifteen healthy older adults and 13 older adults with clinical balance impairment were exposed to balance disturbances by means of sudden movement of a platform on which they stood. A dual-task paradigm where postural recovery served as the primary task and verbal reaction time to auditory tones served as the. secondary task was used to assess attentional demand. To determine the effect of the cognitive task on postural recovery, kinetic, kinematic, and neuromuscular measures of a feet-in-place response were investigated. Results. Balance recovery using a feet-in-place response was attentionally demanding in both groups of older adults and was more demanding in balance-impaired than in healthy elderly persons. With the concurrent performance of a cognitive task, balance-impaired elderly persons took longer to stabilize their center of pressure and regain balance than in a sing le task, while healthy elderly persons showed no change between conditions. In addition, only balance-impaired elderly individuals had a greater center-of-pressure resultant velocity during recovery in a dual-task compared with a single-task Situation. Conclusions. The ability to recover balance using a feet-in-place response was more attentionally demanding in balance-impaired than in healthy elderly persons. The recovery of balance was also slower and less efficient in balance-impaired elderly persons when simultaneously performing a cognitive task, whereas the ability of healthy elderly individuals to recover was not influenced by concurrent task demands. This suggests that dual-task performance may contribute to postural instability and falls in balance-impaired elderly individuals.
TL;DR: The Multi-Directional Reach Test is an inexpensive, reliable, and valid tool for measuring the limits of stability as derived by reach in four directions and values obtained on relatively healthy community-dwelling older adults serve as norms for screening patient populations.
Abstract: Background. Falls occur not only in the forward direction, but also to the side and backward. The purpose of this study was to develop a portable and valid tool to measure limits of stability in the anterior-posterior and medial-lateral directions. Methods. Two hundred fifty-four community-dwelling older persons were administered the Berg Balance Test (BBT), the Timed Up & Go Test (TUG), and the Multi-Directional Reach Test (MDRT). For the MDRT, subjects performed maximal reaches with the outstretched arm forward (FR), to the right (RR), to the left (LR), and leaning backward (BR), with feet flat on the floor. Reach was measured by the subject’s total hand excursion along a yardstick affixed to a telescoping tripod. Results. Mean scores on the MDRT were FR 5 8.89 6 3.4 in., BR 5 4.64 6 3.07 in., RR 5 6.15 6 2.99 in., and LR 5 6.61 6 2.88 in. Interclass Correlation (ICC2,1) for the reaches were greater than .92. Reliability analysis (Cronbach’s Alpha, .842) demonstrated that directional reaches measure similar but unique aspects of the MDRT. The MDRT demonstrated significant correlation with the BBT sum and significant inverse relationship with the scores on the TUG. Regression analysis revealed that activity level contributed to scores in the forward, right, and left direction and that fear of falling contributed to scores in the backward direction.
TL;DR: The results confirmed that women with disability on at least one IADL item are frailer because they had more associated disorders, poorer cognitive function and more frequent falls.
Abstract: Background. A number of clinical conditions have been shown to be associated with frailty in elderly people. We hypothesized that incapacities on the Instrumental Activities of Daily Living (IADLs) scale could make it possible to identify this population. We investigated the associations between IADL incapacities and the various known correlates of frailty in a cohort of community-dwelling elderly women. Methods. Cross-sectional analysis was carried out on the data from 7364 women aged over 75 years (EPIDOS Study). The IADL was the dependent variable. Sociodemographic, medical, and psychological performance measures were obtained during an assessment visit. Falls in the previous 6 months and fear of falling were also ascertained. Body composition was measured by dual-energy x-ray absorptiometry. The factors associated with disability in at least one IADL were included in a logistic regression model. Results. Thirty-two percent of the population studied had disability in at least one IADL item. This group was significantly older (81.7 � 4.1 yr vs 79.8 � 3.4 yr), had more frequent histories of heart disease, stroke, depression or diabetes, and was socially less active ( p � .001). These associations persisted after multivariate analysis. Cognitive impairment as assessed by the Pfeiffer test (Pfeiffer score � 8) was closely associated with disabilities on the IADL (OR 3.101, 95% confidence interval [CI] 2.19‐4.38). Falls and fear of falling were also more frequent in the group of women with an abnormal IADL ( p � .001) but only fear of falling remained significantly associated with incapacities on at least one IADL item after logistic regression (OR 1.47, 95% CI 1.28‐1.69). Women with disability on at least one IADL item also had lower bone mineral density, this was independent of the other factors. Conclusion. Our results confirmed that women with disability on at least one IADL item are frailer because they had more associated disorders, poorer cognitive function and more frequent falls. Disabilities on this scale could be a good tool for identifying individuals at risk of frailty among elderly persons living at home and in apparent good health. This finding requires confirmation by longitudinal studies.
TL;DR: Screening caregivers for burden and depression and designing interventions to decrease the consequences of behavioral disturbance on caregivers would be relevant avenues to explore to decrease institutionalization of people with dementia.
Abstract: Background In Canada, half the people with dementia live in institutions. Factors associated with institutionalization should be identified with the goal of implementing strategies not only to permit those with dementia to stay in their homes as long as is feasible but also to ensure that steps are taken for timely institutionalization when appropriate. Methods Informal caregivers of 326 individuals with dementia living in the community were identified and interviewed as part of the Canadian Study of Health and Aging (CSHA). These subjects were contacted again 2.5 and 5 years after the baseline interview to collect information on the status of their care recipients. Survival analyses using clinical data for the individuals with dementia and data from the interviews with their informal caregivers were carried out using Cox proportional hazard modeling to estimate the hazard ratio (HR). Results Over the 5-year period, 166 individuals with dementia (50.9%) were institutionalized and the median time to admission was 41 months. From the multivariate analysis, the factors significantly associated with institutionalization were: type of dementia (Alzheimer's disease: HR = 1.83), severity of disability (mild: 1.51; moderate: 2.34; total impairment: 4.02), caregiver's age over 60 (1.83), caregiver not a spouse or child (1.55), and severe caregiver burden (1.71). Caregiver's burden was associated with the care-receiver's behavioral disturbance (partial r =.55) and the caregiver's depressive mood (r =.55). Conclusions Screening caregivers for burden and depression and designing interventions to decrease the consequences of behavioral disturbance on caregivers would be relevant avenues to explore to decrease institutionalization of people with dementia.
TL;DR: Several lines of evidence suggest that optimal glycemic control and risk factor modification can substantially reduce the risk of complications in elderly patients with diabetes.
Abstract: Diabetes is common in the elderly population. By the age of 75, approximately 20% of the population are afflicted with this illness. Diabetes in elderly adults is metabolically distinct from diabetes in younger patient populations, and the approach to therapy needs to be different in this age group. Diabetes is associated with substantial morbidity from macro- and microvascular complications. Several lines of evidence suggest that optimal glycemic control and risk factor modification can substantially reduce the risk of complications in elderly patients. In the past, treatment options were limited. However, recent studies have delineated several new and exciting therapeutic opportunities for elderly patients with diabetes.