Indoor and Outdoor Falls in Older Adults Are Different: The Maintenance of Balance,Independent Living,Intellect, and Zest in the Elderly of Boston Study

OBJECTIVES: To identify risk factors for indoor and outdoor falls. DESIGN: Prospective cohort study. SETTING: The MOBILIZE Boston Study, a study of falls etiology in community‐dwelling older individuals. PARTICIPANTS: Seven hundred sixty‐five women and men, mainly aged 70 and older, from randomly sampled households in the Boston, Massachusetts, area. MEASUREMENTS: Baseline data were collected by questionnaire and comprehensive clinic examination. During follow‐up, participants recorded falls on daily calendars. The location and circumstances of each fall were asked during telephone interviews. RESULTS: Five hundred ninety‐eight indoor and 524 outdoor falls were reported over a median follow‐up of 21.7 months. Risk factors for indoor falls included older age, being female, and various indicators of poor health. Risk factors for outdoor falls included younger age, being male, and being relatively physically active and healthy. For instance, the age‐ and sex‐adjusted rate ratio for having much difficulty or inability to perform activities of daily living relative to no difficulty was 2.57 (95% confidence interval (CI)=1.69–3.90) for indoor falls but 0.27 (95% CI=0.13–0.56) for outdoor falls. The rate ratio for gait speed of less than 0.68 m/s relative to a speed of greater than 1.33 m/s was 1.48 (95% CI=0.81–2.68) for indoor falls but 0.27 (95% CI=0.15–0.50) for outdoor falls. CONCLUSION: Risk factors for indoor and outdoor falls differ. Combining these falls, as is done in many studies, masks important information. Prevention recommendations for noninstitutionalized older people would probably be more effective if targeted differently for frail, inactive older people at high risk for indoor falls and relatively active, healthy people at high risk for outdoor falls.     

Characteristics of chronic pain associated with sleep difficulty in older adults: the Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly (MOBILIZE) Boston study

OBJECTIVES: To evaluate pain severity and distribution in relation to sleep difficulty in older adults. DESIGN: Population‐based cross‐sectional study. SETTING: Community within a 5‐mile radius of the study center at the Institute for Aging Research, Hebrew SeniorLife (HSL), Boston. PARTICIPANTS: Seven hundred sixty‐five participants of the Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly (MOBILIZE) Boston Study aged 64 and older. MEASUREMENTS: Pain severity was measured using the Brief Pain Inventory (BPI) Pain Severity Subscale. Musculoskeletal pain distribution was grouped according to no pain, single site, two or more sites, and widespread pain (upper and lower extremities and back pain). Three aspects of sleep difficulty were measured using items from the Center for Epidemiologic Studies Depression Scale, Revised (trouble getting to sleep, sleep more than usual, and restless sleep). RESULTS: Prevalence of trouble getting to sleep according to BPI severity was 17.8%, 19.7%, 32.0%, and 37.0% for the lowest to highest pain severity quartiles, respectively. Similar relationships between pain and sleep were observed across sleep measures according to pain severity and distribution. Adjusted for sociodemographic characteristics, chronic conditions, and health behaviors, chronic pain was strongly associated with trouble sleeping (≥1 d/wk) (single‐site pain, odds ratio (OR)=1.77, 95% confidence interval (CI)=1.10–2.87; multisite pain, OR=2.38, 95% CI=1.48–3.83; widespread pain, OR=2.55, 95% CI=1.43–4.54, each compared with no pain). Similar associations were observed for restless sleep and sleeping more than usual. For specific pain sites alone or in combination with other sites of pain, only modest associations were observed with sleep problems. CONCLUSION: Widespread or other multisite pain and moderate to severe pain are strongly associated with sleep difficulty in older adults. Further research is needed to better understand the burden and consequences of pain‐related sleep problems in older adults.     

The nonlinear relationship between gait speed and falls: the Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly of Boston Study

OBJECTIVES: To examine the relationship between gait speed and falls risk. DESIGN: Longitudinal analysis of the association between gait speed and subsequent falls and analysis of gait speed decline as a predictor of future falls. SETTING: Population‐based cohort study. PARTICIPANTS: Seven hundred sixty‐three community‐dwelling older adults underwent baseline assessments and were followed for falls; 600 completed an 18‐month follow‐up assessment to determine change in gait speed and were followed for subsequent falls. MEASUREMENTS: Gait speed was measured during a 4‐m walk, falls data were collected from monthly post‐card calendars, and covariates were collected from in‐home and clinic visits. RESULTS: There was a U‐shaped relationship between gait speed and falls, with participants with faster (≥1.3 m/s, incident rate ratio (IRR)=2.12, 95% confidence interval (CI)=1.48–3.04) and slower (<0.6 m/s, IRR=1.60, 95% CI=1.06–2.42) gait speeds at higher risk than those with normal gait speeds (1.0–<1.3 m/s). In adjusted analyses, slower gait speeds were associated with greater risk of indoor falls (<0.6 m/s, IRR=2.17, 95% CI=1.33–3.55; 0.6–<1.0 m/s, IRR=1.45, 95% CI=1.08–1.94), and faster gait speed was associated with greater risk of outdoor falls (IRR=2.11, 95% CI=1.40–3.16). A gait speed decline of more than 0.15 m/s per year predicted greater risk of all falls (IRR=1.86, 95% CI=1.15–3.01). CONCLUSION: There is a nonlinear relationship between gait speed and falls, with a greater risk of outdoor falls in fast walkers and a greater risk of indoor falls in slow walkers.     

Outcomes Associated with Opioid Use in the Treatment of Chronic Noncancer Pain in Older Adults: A Systematic Review and Meta‐Analysis

This systematic review summarizes existing evidence regarding the efficacy, safety, and abuse and misuse potential of opioids as treatment for chronic noncancer pain in older adults. Multiple databases were searched to identify relevant studies published in English (1/1/80–7/1/09) with a mean study population age of 60 and older. Forty‐three articles were identified and retained for review (40 reported safety and efficacy data, the remaining 3 reported misuse or abuse outcome data). The weighted mean subject age was 64.1 (mean age range 60–73). Studies enrolled patients with osteoarthritis (70%), neuropathic pain (13%), and other pain‐producing disorders (17%). The mean duration of treatment studies was 4 weeks (range 1.5?156 weeks), and only five (12%) lasted longer than 12 weeks. In meta‐analyses, effect sizes were ?0.557 (P<.001) for pain reduction, ?0.432 (P<.001) for physical disability reduction, and 0.859 (P=.31) for improved sleep. The effect size for the Medical Outcomes Study 36‐item Health Survey was 0.191 (P=.17) for the physical component score and ?0.220 (P=.04) for the mental component score. Adults aged 65 and older were as likely as those younger than 65 to benefit from treatment. Common adverse events included constipation (median frequency of occurrence 30%), nausea (28%), and dizziness (22%) and prompted opioid discontinuation in 25% of cases. Abuse and misuse behaviors were negatively associated with older age. In older adults with chronic pain and no significant comorbidity, short‐term use of opioids is associated with reduction in pain intensity and better physical functioning but poorer mental health functioning. The long‐term safety, efficacy, and abuse potential of this treatment practice in diverse populations of older persons remain to be determined.     

Daily Variations in Objective Nighttime Sleep and Subjective Morning Pain in Older Adults with Insomnia: Evidence of Covariation over Time

OBJECTIVES: To examine the relationship between objectively measured nocturnal sleep and subjective report of morning pain in older adults with insomnia; to examine not only the difference between persons in the association between sleep and pain (mean level over 14 days), but also the within‐person, day‐to‐day association. DESIGN: Cross‐sectional. SETTING: North‐central Florida. PARTICIPANTS: Fifty community‐dwelling older adults (mean age±standard deviation 69.1±7.0, range 60–90) with insomnia. MEASUREMENTS: Daily home‐based assessment using nightly actigraphic measurement of sleep and daily self‐report of pain over 14 consecutive days. RESULTS: Between persons, average sleep over 14 days was not associated with average levels of rated pain, but after a night in which an older adult with insomnia experienced above‐average total sleep time he or she subsequently reported below‐average pain ratings. The model explained approximately 24% of the within‐person and 8% of the between‐person variance in pain ratings. CONCLUSIONS: Sleep and pain show day‐to‐day associations (i.e., covary over time) in older adults with insomnia. Such associations may suggest that common physiological systems underlie the experience of insomnia and pain. Future research should examine the crossover effects of sleep treatment on pain and of pain treatment on sleep.     

A Comparison of Cognitive and Everyday Functional Performance Among Older Adults With and Without Hypertension

Secondary data analyses examined the differences in cognitive and instrumental activities of daily living (IADL) performance among hypertensive individuals taking one of four classes of antihypertensive medications, hypertensive individuals not taking any antihypertensive medications, and normotensive individuals (N?=?770). After adjusting for covariates, significant group differences were evident on all measures (speed of processing, motor speed, reaction time, p < .05) except memory and timed IADL (p > .05). Follow-up a priori planned comparisons compared hypertensive individuals not on medications to each of the four antihypertensive medication groups. Results indicated that only those on beta-blockers were significantly slower in speed of processing (p < .05). A priori planned comparisons also revealed that normotensive individuals had better cognitive performance on measures of processing speed, motor speed, and reaction time than hypertensive individuals regardless of antihypertensive medication use. Additionally, normotensive individuals performed significantly better on memory (digit and spatial span) than individuals with hypertension on medications. No differences were found between groups on memory (Hopkins Verbal Learning Test) or timed IADL performance. With regard to antihypertensive medications, the use of beta blockers was associated with slowed processing speed. These analyses provide empirical evidence that hypertension primarily impacts speed of processing, but not severe enough to affect IADL performance. Given the contribution of processing speed to memory and executive function performance, this is an important finding. Clinicians need to take into consideration the potential negative impact that beta blockers may have on cognition when determining the best treatment of hypertension among older adult patients.     

Patterns of Functional Disability in the Oldest Adults in China

This study examined patterns of onset of activity of daily living (ADL) disability in a nationally representative sample of older adults in mainland China. Using longitudinal data from the Chinese Longitudinal Healthy Longevity Survey from 1998 to 2008 (N = 5,570), nonparametric methods were used to evaluate median age at onset of various ADL disabilities and differences in the incidence of disabilities according to sex. The sampled older Chinese adults developed ADL disabilities, on average, between the ages of 89 and 94. Women were likely to experience later onset than men. The results also show that the oldest adults generally lose bathing ability, followed by toileting, transferring, dressing, eating, and finally, continence. This order—derived from estimated median age at onset—was also found to be highly prevalent in subsequently disabled respondents in the sample. The disability experience of older adults in China is somewhat similar to that of older adults in Western developed countries; elderly adults tend to lose ability in activities that require lower extremity strength earlier than those that require upper extremity strength. The relative importance of the various ADL items in the hierarchical ordering has implications for early intervention to reduce the risk of functional disability in older adults and those at risk of transitions of care.     

Factors Associated with Accurate Recall of Prior Disability in Older Persons

OBJECTIVES: To identify the factors associated with accurate recall of prior disability.
DESIGN: Cohort study.
SETTING: Greater New Haven, Connecticut.
PARTICIPANTS: Ninety-two participants, included in each of two analytical samples, who were nondisabled at the present time in four essential activities of daily living (ADLs; bathing, dressing, transferring, and walking) but who had had at least 1 month of disability during the prior year as determined from monthly telephone interviews.
MEASUREMENTS: Participants who did not need help from another person at the present time were asked to recall whether they had needed help from another person to complete the relevant ADL at any time during the previous 12 months.
RESULTS: Forty-five (48.9%) and 46 (50.0%) of the 92 participants accurately recalled having had disability in the prior year in the first and second analytical samples, respectively. Having at least a high school education was the only factor independently associated with accurate recall in the first analytical sample, with an adjusted odds ratio (AOR) of 3.03 (95% confidence interval (CI)=1.11−8.31), whereas a composite disability scale that considered the timing and severity of prior disability was the only factor independently associated with accurate recall in the second analytic sample (AOR=5.38, 95% CI=1.81−16.1).
CONCLUSION: The results of the current study, coupled with those of previous studies, suggest potential strategies that could be used to more completely and accurately ascertain the occurrence of disability in older persons.     

Ambient particulate matter and the response to orthostatic challenge in the elderly: the Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly (MOBILIZE) of Boston study

Short-term elevations in ambient fine particulate matter (PM(2.5)) may increase resting systolic (SBP) and diastolic (DBP) blood pressures, but whether PM(2.5) alters hemodynamic responses to orthostatic challenge has not been studied in detail. We repeatedly measured SBP and DBP during supine rest and 1 and 3 minutes after standing among 747 elderly (aged 78.3±5.3 years, mean±SD) participants from a prospective cohort study. We used linear mixed models to assess the association between change in SBP (ΔSBP=standing SBP-supine SBP) and DBP (ΔDBP) on standing and mean PM(2.5) levels over the preceding 1 to 28 days, adjusting for meteorologic covariates, temporal trends, and medical history. We observed a 1.4-mm Hg (95% CI: 0.0-2.8 mm Hg; P=0.046) higher ΔSBP and a 0.7-mm Hg (95% CI: 0.0-1.4 mm Hg; P=0.053) higher ΔDBP at 1 minute of standing per interquartile range increase (3.8 μg/m(3)) in mean PM(2.5) levels in the past 7 days. ΔSBP and ΔDBP measured 3 minutes after standing were not associated with PM(2.5). Resting DBP (but not SBP or pulse pressure) was positively associated with PM(2.5) at longer averaging periods. Responses were more strongly associated with black carbon than sulfate levels. These associations did not differ significantly according to hypertension status, obesity, diabetes mellitus, or sex. These results suggest that ambient particles can increase resting DBP and exaggerate blood pressure responses to postural changes in elderly people. Increased vasoreactivity during posture change may be responsible, in part, for the adverse effect of ambient particles on cardiovascular health.     

Performance Measures Predict Onset of Activity of Daily Living Difficulty in Community‐Dwelling Older Adults

OBJECTIVES: To assess the predictive value of five performance‐based measures for the onset of difficulty in activities of daily living (ADLs). DESIGN: A prospective cohort study; home visits every 6 months for 18 months. SETTING: Community‐based. PARTICIPANTS: Community‐dwelling older adults, n=110, (mean age 80.3±7.0; range 67–98) who reported no difficulty in basic ADLs. MEASUREMENTS: The Short Physical Performance Battery (SPPB), gait speed, Berg Balance Scale (BBS), grip strength, and Timed Up and Go Test (TUG) were evaluated at baseline. Seven ADL items were assessed at baseline and 6, 12, and 18 months. The onset of ADL disability was self‐report of difficulty in any of the seven ADL items. Logistic regression models were fitted for each of the physical performance measures to predict onset of ADL difficulty at 6, 12, and 18 months. RESULTS: After controlling for age, comorbid conditions, and sex, the BBS was the most consistent and best predictor for the onset of ADL difficulty over an 18‐month period (6 months, c‐statistic=0.725, (95% confidence interval (CI)=0.60–0.85; 12 months, c‐statistic=0.840 95% CI=0.75, 0.93; 18 months, c‐statistic=0.821, 95% CI=0.71, 0.93). The SPPB showed excellent predictive value for the onset of difficulty at 12 months. Ninety‐five, 89, and 75 older adults completed the 6, 12, and 18‐month follow‐up visits, respectively. CONCLUSION: BBS, followed by SPPB, TUG, gait speed, and grip strength, were predictive of the onset of ADL difficulty over an 18‐month period in community‐dwelling older adults. Screening nondisabled older adults with simple performance tests could allow clinicians to identify those at risk for ADL difficulty and may help to detect early functional decline.