Self-reported functional ability predicts three-year mobility and mortality in community-dwelling older persons

Background:  A comprehensive evaluation of the functions of community-dwelling older persons was conducted in 1988. Three years after the 1988 study commenced, the relationship between these background factors and changes during the subsequent 3 years were examined.
Methods:  The study was a comprehensive evaluation of the daily functions of community-dwelling elderly people, and encompassed age, gender, mode of living, marital status, financial status, family relationships, basic activities of daily living, visual and hearing impairment, a history of disease, self-related feeling, social role, social support, habits and physical exercise and the relationship between independence and survival for 3 years after the basic study. The subjects were 2274 community-dwelling elderly people who participated in the first survey in July 1998 and who were aged 65 years and over at that time. Unassisted questionnaire sheets were used for the first survey and changes since the first survey.
Results:  Thirty men and 60 women died during the 3 year period. Data were also gathered about the daily activity levels of 1709 persons (75.2%) with 1499 (87.7%) ranking J for independence and 210 persons (12.3%) ranking A to C for dependence. Age, gender, basic activities of daily living (BADL), history of falls, self-related happiness, participation in community events and physical-exercise habits were found to be explanatory variables for independence after three years; as were age, gender, and BADL for survival.
Conclusion:   The explanatory variables relating to independence and prognosis of life of the elderly obtained in this study will be important in future considerations of the issue of care-taking and measures to enable it.     

Estimated functional capacity predicts mortality in older adults

OBJECTIVES: To examine associations between functional capacity estimated from cardiorespiratory fitness (CRF) and mortality risks in adults aged 60 and older.
DESIGN: Prospective study, averaging 13.6 years follow-up.
SETTING: Preventive medical clinic.
PARTICIPANTS: Four thousand sixty adults who completed preventive medical examinations between 1971 and 2001; 24.7% women, mean age±standard deviation 64.6±4.9, body mass index (BMI) 25.9±3.8 kg/m².
MEASUREMENTS: CRF was quantified as metabolic equivalents (METs) achieved during maximal treadmill exercise. The lowest 20% of the age- and sex-specific MET distribution was defined as having low CRF, the middle 40% moderate CRF, and the upper 40% high CRF. Cox regression was used to estimate death rates (per 1,000 person-years), hazard ratios (HRs), and their 95% confidence intervals (CIs).
RESULTS: Nine hundred eighty-nine deaths occurred during follow-up. Death rates adjusted for age, sex, and examination year were 30.9, 18.3, and 13.4 for all causes ( P <.001); 15.9, 8.6, and 5.4 for cardiovascular disease (CVD) ( P <.001); and 6.1, 4.9, and 4.2 for cancer ( P =.04) for subjects with low, moderate, and high CRF, respectively. After adjusting for smoking, abnormal electrocardiograms at rest or while exercising, percentage of age-predicted maximal heart rate achieved during exercise testing, baseline medical conditions, BMI, hypercholesterolemia, and family CVD and cancer history, subjects with high CRF had notably lower mortality risk than those with low CRF from all causes (HR=0.59, 95% CI=0.47–0.74) and from CVD (HR=0.57, 95% CI=0.41–0.80).
CONCLUSION: CRF is an important independent predictor of death in older adults. The results add to the existing evidence that promoting physical activity in older adults provides substantial health benefits, even in the oldest old.     

Reliability of the hierarchical assessment of balance and mobility in frail older adults

OBJECTIVES: To study the test–retest and interrater reliability of the Hierarchical Assessment of Balance and Mobility (HABAM) in frail older adults.
DESIGN: Convenience sample of 167 frail older adults seen as part of routine care by an academic geriatrician at a tertiary care teaching hospital.
SETTING: Inpatient medical and geriatric wards, geriatric ambulatory care clinic, emergency department, home visits.
PARTICIPANTS: The interrater reliability sample consisted of 98 inpatients and 69 outpatients. The test–retest reliability sample tracked 63 of the inpatients over the first 2 days of their hospital stay.
MEASUREMENTS: Mobility and balance were assessed using the HABAM. Frailty was assessed using a frailty index based on a standardized Comprehensive Geriatric Assessment. Reliability was assessed using Pearson correlations and the intraclass correlation coefficients.
RESULTS: The interrater reliability of the HABAM was 0.92 and ranged from 0.88 to 0.96 across settings for the various components (balance, transfers, mobility). Test–retest reliability was 0.91 (range 0.85–0.92).
CONCLUSION: The HABAM appears to be a reliable means of assessing mobility and balance in frail older adults.     

Oxygen-uptake (VO2) kinetics and functional mobility performance in impaired older adults

BACKGROUND: Measures of maximal oxygen uptake (VO(2max)) are limited in disabled older adults, and measures of submaximal oxygen uptake (VO(2)) may better predict functional mobility limitations. These measures may include oxygen-uptake kinetics at the onset of submaximal exercise or during recovery. We sought to determine whether the lag in oxygen uptake at the beginning of exercise (oxygen deficit) and excess oxygen uptake above rest following exercise (excess postexercise oxygen consumption) (a) predict physical performance in impaired older adults with decreased aerobic function, and (b) predict physical performance better than peak VO(2). METHODS: Two groups of community-dwelling volunteers aged 65 or older were recruited according to their performance on a maximal graded exercise test. Using the Social Security Administration criterion of disability of a peak VO(2) 18 (Unimpaired, n = 21, mean +/- SEM age 76 +/- 1 years). RESULTS: The mean +/- SEM peak VO(2) was 58% lower in the Impaired (14 +/- 1 ml/kg/min) than the Unimpaired (24 +/- 1 ml/kg/min) adults. The time constant for oxygen deficit, tc(deficit), was more than twice as high in the Impaired than the Unimpaired (p <.05), and the time constant for excess postexercise oxygen consumption, tc(EPOC), tended to be higher in the Impaired than the Unimpaired (by 43%, p =.09). Measures of submaximal oxygen-uptake kinetics were as strong or more strongly predictive of functional mobility performance than peak VO(2) in both Unimpaired and Impaired older adults. The major predictor of functional performance for the Unimpaired was a measure of oxygen deficit accruing during exercise (tc(deficit)), and for the Impaired, it was a measure of oxygen debt during recovery, tc(EPOC). CONCLUSIONS: Measurement of submaximal oxygen-uptake kinetics may provide a more practical and relevant assessment of deconditioning in frail older adults, and may eventually supplant maximal (peak) oxygen uptake as a predictor of functional disability in older adults.     

Trajectories of cognitive decline and functional status in the frail older adults

This study investigates the implications of different levels of cognitive decline on functional status in frail older adults. Four cognitive trajectories, including two with catastrophic cognitive decline, were defined in a 3-year study. Participants with complete cognitive and functional status data at baseline, 12 and 36 months of follow-up were included in the study (n=456). Data were analysed with repeated measures statistics. Substantial functional deterioration over time was observed for the participants with catastrophic cognitive decline. Catastrophic cognitive decline influenced performance in instrumental activities of daily living (IADL) and activities of daily living (ADL) at 12 months, whereas basic physical and mental actions were affected at 36 months. IADL were found to deteriorate more than ADL. The results have implications on planning appropriate geriatric rehabilitation and long-term care program.     

Metabolic syndrome predicts mobility decline in a community-based sample of older adults

OBJECTIVES: To determine whether metabolic syndrome is an independent predictor of decline in mobility in an elderly community sample. DESIGN: Biracial community-based prospective cohort study. SETTING: Urban and rural areas of central North Carolina. PARTICIPANTS: One thousand two hundred twenty-nine older African Americans and whites, mean age 77.0, who were participants in the Duke Established Populations for Epidemiologic Studies of the Elderly. MEASUREMENTS: Sociodemographic data and data on mobility (a subset of items from the Rosow-Breslau scale), depression (Center for Epidemiological Studies Depression Scale), self-report of medical conditions, body mass index, cognitive function (Short Portable Mental Status Questionnaire), blood pressure, height, and waist circumference. High-density lipoprotein cholesterol, triglycerides, and blood glucose were available from blood samples. Metabolic syndrome was calculated for subjects with complete data. RESULTS: Twenty-nine percent of the sample met criteria for metabolic syndrome. In bivariate analyses, age, sex, race, education, cognitive impairment, depression, impairment in mobility, history of stroke and heart disease, and metabolic syndrome at baseline were associated with a decline in mobility 4 years later. Regression analysis controlling for the above variables demonstrated that metabolic syndrome persisted as an independent and highly significant predictor of decline in mobility. CONCLUSION: These findings suggest that metabolic syndrome may be a distinct risk factor for mobility decline in community-dwelling older people.     

Self-efficacy mediates walking performance in older adults with knee osteoarthritis

BACKGROUND: Self-efficacy is a determinant of walking performance in older adults with knee osteoarthritis. We examined whether self-efficacy mediated the effect of age, psychosocial, impairment, and mechanical factors on walking performance. METHODS: Fifty-four participants with knee osteoarthritis completed the Six Minute Walk test and Arthritis Self-Efficacy Scale. Independent variables reflected age, psychosocial (depressive symptoms), impairment (pain, stiffness), and mechanical (strength, obesity) factors. RESULTS: Self-efficacy fully mediated the effect of age and impairments on walking. The effects of strength were only partially mediated by self-efficacy. Depressive symptoms and obesity were not mediated by self-efficacy. CONCLUSIONS: These findings are consistent with Social Cognitive Theory, according to which age may alter outcome expectations, and impairments like pain and stiffness provide negative physiological feedback to influence performance. Mechanical factors like strength and obesity may better represent a person's capabilities and interact with other variables to influence physical performance in older adults with knee osteoarthritis.     

Low mobility during hospitalization and functional decline in older adults

OBJECTIVES: To examine the association between mobility levels of older hospitalized adults and functional outcomes. DESIGN: Prospective cohort study. SETTING: A 900‐bed teaching hospital in Israel. PARTICIPANTS: Five hundred twenty‐five older (≥70) acute medical patients hospitalized for a nondisabling condition. MEASUREMENTS: In‐hospital mobility was assessed using a previously validated scale. The main outcomes were decline from premorbid baseline functional status at discharge (activities of daily living (ADLs)) and at 1‐month follow‐up (ADLs and instrumental ADLs (IADLs)). Hospital mobility levels and functional outcomes were assessed according to prehospitalization functional trajectories. Logistic regressions were modeled for each outcome, controlling for functional status, morbidity, and demographic characteristics. RESULTS: Forty‐six percent of participants had declined in ADLs at discharge and 49% at follow‐up; 57% had declined in IADLs at follow‐up. Mobility during hospitalization was twice as high in participants with no preadmission functional decline. Low versus high in‐hospital mobility was associated with worse basic functional status at discharge (adjusted odds ratio (AOR)=18.03, 95% confidence interval (CI)=7.68–42.28) and at follow‐up (AOR=4.72, 95% CI=1.98–11.28) and worse IADLs at follow‐up (AOR=2.00, 95% CI=1.05–3.78). The association with poorer discharge functional outcomes was present in participants with preadmission functional decline (AOR for low vs high mobility=15.26, 95% CI=4.80–48.42) and in those who were functionally stable (AOR for low vs high mobility=10.12, 95% CI=2.28–44.92). CONCLUSION: In‐hospital mobility is an important modifiable factor related to functional decline in older adults in immediate and short‐term (1‐month follow‐up) functional outcomes.     

Emergency housing for frail older adults

The emergency housing program described provides immediately available beds in private homes for homeless, impaired elderly adults. Clients receive 24-hour care for two to four weeks while permanent housing arrangements are made. Compared to traditional programs for the homeless, the emergency program saved money and provided more positive social support. A year later clients were significantly less likely to be institutionalized than were comparable nonparticipants.     

Sensory and cognitive factors influencing functional ability in older adults

BACKGROUND: Age-related sensory and cognitive impairments have been related to functional performance in older adults. With regard to cognitive abilities, processing speed in particular may be strongly related to older adults' abilities to perform everyday tasks. Identifying and comparing cognitive correlates of functional performance is particularly important in order to design interventions to promote independence and prevent functional disability. OBJECTIVE: The present study examined the relative importance of cognitive (specifically, speeded and nonspeeded) and sensory factors in relation to older adults' functional abilities. Functional abilities included measures of mobility and performance of everyday activities. METHODS: A cross-sectional study design was employed. Five hundred and thirty adults between the ages of 62 and 94 completed measures of sensory, cognitive (including processing speed, attention, memory, intelligence) and functional abilities. RESULTS: Overall, functional performance was most strongly associated with cognitive speed performance, but nonspeeded cognitive and sensory abilities also accounted for significant amounts of variance in functional performance. Age explained a small but statistically significant amount of additional variance in some functional abilities, but no additional variance in self-reported mobility measures. CONCLUSION: These findings point to the potential impact of multifaceted training programs, targeting both sensory and cognitive abilities for maintaining functional abilities.     

Effects of sensorimotor adaptation training on functional mobility in older adults

The goal of this study was to determine if prolonged exposure to perceptual-motor mismatch increased adaptability and retention of balance in older adults. Sixteen adults, aged 66 to 81 years, were randomized to one of two groups: either the control group (n=8) or the experimental group (n=8). Both groups first completed six trials of walking an obstacle course. Participants then trained twice a week for 4 weeks. In the training, the control group walked on a treadmill for 20 minutes while viewing a static visual scene and the experimental group walked on a treadmill for 20 minutes while viewing a rotating visual scene that provided a perceptual-motor mismatch. Following training, both groups were post-tested on the obstacle course. The experimental group moved faster through the obstacle course with fewer penalties. This training effect was retained for 4 weeks. Exposure to perceptual-motor mismatch induced an adaptive training effect that improved balance and locomotor control in older adults.     

Preclinical mobility disability predicts incident mobility disability in older women

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 self-reported incident difficulty walking 1/2 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 1/2 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 (1/3 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.     

Fatigue predicts mortality in older adults

OBJECTIVES: To determine the association between fatigue and survival over 10 years in a population of older community‐dwelling primary care patients. DESIGN: Prospective cohort study. SETTING: Medicare health maintenance organization and Veterans Affairs primary care programs. PARTICIPANTS: Older primary care patients (N=492). MEASUREMENTS: Fatigue, operationalized as feeling tired most of the time, was assessed at baseline. Mortality was ascertained from the National Death Index. Covariates included demographics, comorbidity, cognitive function, depressive symptoms, body mass index, self‐rated health, functional status, and gait speed. RESULTS: Mortality rates at 10 years were 59% (123/210) for older adults with fatigue, versus 38% (106/282) for those without fatigue (P<.001). After adjustment for multiple potential confounders, participants who were tired at baseline had a greater risk of death than those who were not (hazard ratio=1.44, 95% confidence interval=1.08–1.93). CONCLUSION: A single simple question “Do you feel tired most of the time?” identifies older adults with a higher risk of mortality. Further research is needed to identify and characterize the underlying mechanisms of fatigue, to develop and test specific treatments, and to determine whether improvement leads to decreased morbidity and mortality.     

Outcomes of pain in frail older adults with dementia

OBJECTIVES: To describe the outcomes of pain in cognitively impaired older adults in a Program of All-inclusive Care for older people (PACE) setting and to determine whether pain and psychotropic drug use, behavioral disturbances, hospital, nursing facility, and emergency department use, or mortality increases with the level of pain reported. DESIGN: Retrospective review of an observational cohort of patients with dementia. SETTING: A first-generation PACE program located in Portland, Oregon. Patients with the diagnosis of dementia had been assessed for pain in a prior study. PARTICIPANTS: One hundred fifty-four cognitively impaired subjects. MEASUREMENTS: Standardized pain assessments were administered to cognitively impaired subjects between June and October 1998. After the pain assessment, information about mortality and healthcare use, including use of medication, was collected and analyzed. Subjects who reported moderate to severe pain were compared with demented subjects who reported no or mild pain. RESULTS: There were no differences in patient characteristics (age, sex, functional limitations, disruptive behaviors, and incontinence), medications (pain and psychotropic), use (hospital, nursing home, or emergency department visit), or mortality by level of pain alone or by levels of pain and dementia together. CONCLUSIONS: The study did not demonstrate that a single point-in-time measurement of pain in demented persons was associated with an increased rate of behavioral problems, narcotic use, or hospital or emergency department use over the following year. Prospective studies are needed that measure pain over time to determine more accurately the relationship between pain and negative outcomes in dementia.