The falling risk and physical fitness in older people

Aims of this study was to analyze the correlation between the falling risk and their physical fitness, determining the top parameters affecting the falling risk, and preparing an evaluation procedure for the medical department working on this issue for the old people in retirement homes. This study includes 60 persons whose mean age was 73.3 ± 6.6 years. Their demographic characteristics, cognitive function, their balance, falling risk and their physical fitness level have been evaluated. A survey has been done to determine their demographic features. The cognitive function was determined using mini-mental state examination (MMSE) test; for falling risk the Berg balance test (BBT) and balance by standing on one foot test were used, and the physical fitness was determined by senior fitness test (SFT). While the BBT correlation between chair stand, arm curl and 2-min step test are positive; but the correlation between BBT and ‘8-foot up-and-go test’ were negative. However, there was no correlation between the BBT and chair sit-and-reach test, back scratch test (p > 0.05). Due to the results of logistic regression models in order to find out the variations affecting the falling risk most, it has been showed that ‘8-foot up-and-go test’ was reliable. Additionally the subjects probability performing the ‘8-foot up-and-go’ before 8.14 s was OR = 11 (95% confidence interval = 95%CI = 2.25-53.84) times more with maximum 56 points in BBT. We have shown that the falling risk increases with declining of upper and lower extremity muscle strength, aerobic endurance, agility and dynamic balance performance. Agility and dynamic balance performance were mostly relevant with falling risk. We concluded that the old persons’ falling risk and physical fitness level should be evaluated in some intervals. According to their falling risks and physical fitness level, the rehabilitation programs should be programmed to decrease their falling risk, and to increase lower and upper extremity muscle strength, aerobic endurance and especially their agility and dynamic balance performance.     

Relationship between dental occlusion and physical fitness in an elderly population

BACKGROUND: The relationship between physical fitness and dental health status in elderly adults is still unknown. The purpose of the present study is to examine the relationship between physical fitness and occlusal condition of natural teeth in the elderly population. The sample consisted of 591 individuals aged 70 years and 158 aged 80 years selected from the registry of residents in Niigata city. METHODS: Hand grip strength (kg), leg extensor strength (kg), leg extensor power (watts), stepping rate (time per 10 seconds), and one-leg standing time with eyes open (seconds) were measured. The Eichner index was used as a measurement of occlusal condition. It was based on existing natural tooth contacts between maxilla and mandible in the bilateral premolar and molar regions and determined the three groups of classification used. In comparing physical fitness with Eichner index, multiple regression models were developed to adjust for variables such as age, gender, height, body weight, past medical history, blood pressure, serum albumin concentration, presence of lower back pain, smoking habit, marital status, and education. RESULTS: Multiple regression analyses revealed that leg extensor power (R(2) =.627, p <.05), stepping rate (R(2) =.159, p <.05), and one-leg standing time with eyes open (R(2) =.179, p <.05) showed significant correlations with the Eichner index. CONCLUSIONS: Leg extensor power, stepping rate, and one-leg standing time with eyes open are useful indicators in evaluating lower extremity dynamic strength, agility, and balance function, respectively. These findings suggest that dental occlusal condition is associated with lower extremity dynamic strength, agility, and balance function in elderly adults.     

Constructing an index of physical fitness age for Japanese elderly based on 7-year longitudinal data: sex differences in estimated physical fitness age

A standardized method for assessing the physical fitness of elderly adults has not yet been established. In this study, we developed an index of physical fitness age (fitness age score, FAS) for older Japanese adults and investigated sex differences based on the estimated FAS. Healthy elderly adults (52 men, 70 women) who underwent physical fitness tests once yearly for 7 years between 2002 and 2008 were included in this study. The age of the participants at the beginning of this study ranged from 60.0 to 83.0 years. The physical fitness tests consisted of 13 items to measure balance, agility, flexibility, muscle strength, and endurance. Three criteria were used to evaluate fitness markers of aging: (1) significant cross-sectional correlation with age; (2) significant longitudinal change with age consistent with the cross-sectional correlation; and (3) significant stability of individual differences. We developed an equation to assess individual FAS values using the first principal component derived from principal component analysis. Five candidate fitness markers of aging (10-m walking time, functional reach, one leg stand with eyes open, vertical jump and grip strength) were selected from the 13 physical fitness tests. Individual FAS was predicted from these five fitness markers using a principal component model. Individual FAS showed high longitudinal stability for age-related changes. This investigation of the longitudinal changes of individual FAS revealed that women had relatively lower physical fitness compared with men, but their rate of physical fitness aging was slower than that of men.     

Handgrip strength as a predictor of higher-level competence decline among community-dwelling Japanese elderly in an urban area during a 4-year follow-up

This 4-year observational study examined whether handgrip strength can predict functional decline in higher-level competence in a cohort of urban community-dwelling Japanese elderly. Subjects were 406 community-dwelling Japanese, 65 years or older at baseline who scored as “independent in higher-level competence” (11 and over) according to the Tokyo Metropolitan Institute of Gerontology Index of Competence (TMIG-IC). Independent variables were handgrip strength and usual walking speed at baseline survey. Dependent variables were functional status in higher-level competence at 4-year follow-up. Logistic regression analysis, after adjustment for age and body mass index (BMI), revealed that handgrip strength was significantly correlated with decline of higher-level competence in both sexes. Usual walking speed was significantly correlated with decline in higher-level competence only in women. This study revealed that handgrip strength is a predictor for decline in higher-level competence in urban community-dwelling Japanese elderly men and women. Results suggest that handgrip strength may be used to screen for functional capacity decline in community-dwelling elderly.     

Handgrip strength as a predictor of higher-level competence decline among community-dwelling Japanese elderly in an urban area during a 4-year follow-up

This 4-year observational study examined whether handgrip strength can predict functional decline in higher-level competence in a cohort of urban community-dwelling Japanese elderly. Subjects were 406 community-dwelling Japanese, 65 years or older at baseline who scored as “independent in higher-level competence” (11 and over) according to the Tokyo Metropolitan Institute of Gerontology Index of Competence (TMIG-IC). Independent variables were handgrip strength and usual walking speed at baseline survey. Dependent variables were functional status in higher-level competence at 4-year follow-up. Logistic regression analysis, after adjustment for age and body mass index (BMI), revealed that handgrip strength was significantly correlated with decline of higher-level competence in both sexes. Usual walking speed was significantly correlated with decline in higher-level competence only in women. This study revealed that handgrip strength is a predictor for decline in higher-level competence in urban community-dwelling Japanese elderly men and women. Results suggest that handgrip strength may be used to screen for functional capacity decline in community-dwelling elderly.     

Impact of retinal vein occlusion on cardiovascular events in elderly Japanese patients

To assess the relationship between retinal vein occlusion (RVO) and the incidence of cardiovascular (CV) events.This was a single-institution, retrospective cohort study. We enrolled 57 patients diagnosed with RVO between January 2012 and December 2019, and 125 non-RVO patients who had undergone cataract surgery by a single surgeon between January and April 2012. We compared the relative risk and incidence rate ratio of CV events between the 2 groups. In addition, survival analysis was performed to calculate the hazard ratio (HR) using the Cox proportional hazards model. RVO, age, sex, blood pressure, body mass index, presence of diabetes, blood sample data, and smoking were considered confounders.The mean observation period (± standard deviation) for the RVO and non-RVO groups was 2.68 ± 2.04 and 2.81 ± 2.70 years, respectively. Seven CV events were observed in the RVO group and 2 in the non-RVO group. Relative risk and incidence rate ratio were 7.68 (95% confidence interval [CI]: 1.65–35.8) and 8.07 (95% CI: 1.54–79.6), respectively. Multivariate analysis revealed that the RVO group had a high HR for CV events (HR: 16.13 [95% CI: 2.29–113.74]) and older age (HR: 1.26 [95% CI: 1.06–1.49]).RVO can predict future CV events, especially in the elderly population. Fundus observations should be shared between ophthalmologists and internists to prevent future CV events.     

Evaluation of physical fitness in patients with Type 2 diabetes mellitus

Purpose: The aim of this study was to compare functional capacity in 30 Type 2 Diabetic patients with 30 healthy non-diabetic control subjects. Methods: Physical fitness was evaluated using the “EUROFIT Physical Fitness Test Battery”. This battery estimates body composition, cardiopulmonary, musculoskeletal and motor fitness. Results: Percentage of body fat (PBF) was higher in the diabetic compared with control groups (P<0.05) although body mass index (BMI) was similar. Biceps and suprailiac skinfold thickness were also greater in the diabetic group (P<0.05). The 6-min walking distance and VO_2max were significantly lower in the diabetic group (P<0.05). The diabetic patients had lower values of the single leg balance test with eyes opened and closed. Jump-stretch, handgrip and side-bending of trunk tests were also lower in the diabetic patients. Conclusion: Physical functional capacity is lower in Type 2 diabetic patients than in age-matched control subjects.     

Long-term effects of memory training in the elderly: a longitudinal study

The effects of different types of memory training in young and older adults reported in a previous study [Cavallini, E., Pagnin, A., Vecchi, T., 2003. Aging and everyday memory: the beneficial effect of memory training. Arch. Gerontol. Geriatr. 37, 241-257] were again investigated from a longitudinal perspective 2 years after the original memory training sessions. The authors retested the original participants to measure the long-term effectiveness of two mnemonic strategies: the loci technique and strategic training. Three groups of participants (13 adults, M=24.1, 13 younger elderly, M=64.2 and 13 older elderly, M=74.4) were tested using a battery of seven tasks and four questionnaires, to evaluate memory performance and metamemory variables. The three age groups and the two trainings showed similar results on memory performance. Long-term effects were found only on two memory tasks, both were highly related to everyday life showing that, without additional practice, memory performance tended to go back to the original level. Moreover, the beneficial effects of the previous training sessions were particularly evident for older adults in metamemory knowledge and for strategic training in memory complaints. Results partially support the durability of memory training in improving memory performance.     

Correlation between dental and nutritional status in community‐dwelling elderly Japanese

Aim: The purpose of this study was to clarify the correlation between dental and nutritional status among community‐dwelling elderly Japanese people. Methods: The subjects were 182 elderly individuals, aged 65–85 years, who voluntarily participated in a health seminar at Kyoto Prefectural University of Medicine. These subjects were divided into two groups according to the occlusion. The subjects in the retained contact group were those who had retained molar occlusion with natural teeth. The lost contact group were those who retained molar occlusion with removable partial dentures. Anthropometric variables such as body mass index (BMI) were collected and dietary intake was assessed using a brief self‐administered diet history questionnaire (BDHQ). Results: No statistical difference in BMI or intake of macronutrients was found between these two occlusal groups. The lost contact group reported significantly lower consumption of vegetables and higher consumption of confectionaries (foods rich in sugar) than did the retained contact group (P < 0.05), and therefore had significantly lower intake of vitamin C and dietary fiber (P < 0.05). Conclusion: It can be concluded that natural tooth contact loss in the posterior region affect the intake of vitamins and dietary fiber. Geriatr Gerontol Int 2011; 11: 315–319.     

The relationships among the skeletal muscle mass index,cardiorespiratory fitness and the prevalence of coronary artery disease in the elderly population

ObjectiveFew studies have investigated the association between cardiorespiratory fitness (CRF) impairment and coronary artery disease (CAD) and the mediating mechanism. Therefore, we investigated the impact of skeletal muscle mass (SMM) on the relationship between CRF and coronary artery disease (CAD) in elderly people.MethodsIn this cross-sectional study, 109 elderly patients with coronary artery stenosis ≥50% were included in the CAD group, and 148 patients with coronary artery stenosis <50% were included as controls. Mediation analyses were performed to determine the role of the skeletal muscle index (SMI) in the relationship between CRF and the prevalence of CAD. A receiver operating characteristic (ROC) curve analysis was used to evaluate the predictive value of CRF markers and the SMI.ResultsThe oxygen pulse, VO₂ max, and MET max were significantly associated with the SMI. In the multiple logistic regression analyses, the oxygen pulse and SMI were both independently correlated with the prevalence of CAD. The mediation analyses showed that the SMI affects the relationship between CRF markers (oxygen pulse, VO₂ max, and MET max) and the prevalence of CAD. The receiver operating characteristic (ROC) curve analysis showed that when CRF and the SMI are considered together, the predictive power for CAD is stronger than that of the CRF alone.ConclusionEnhancing CRF can facilitate improvement in SMM and decrease the prevalence of CAD in the elderly population. The addition of the SMI to CRF markers may increase the predictive value of CAD.     

Preventive fraction of physical fitness on risk factors in cardiac patients: Retrospective epidemiological study

AIM To quantify the preventive fraction of physical fitness on the risk factors in patients with cardiovascular diseases(CVDs).METHODS A total of 249 subjects(205 men and 44 women) suffering from CVD were categorized into four groups, according to their percentage of physical fitness. We calculated the odds ratio to obtain the preventive fraction in order to evaluate the impact of the physical fitness level on the risk factors(i.e., abdominal obesity, depression, diabetes, dyslipidemia, hypertension, obesity, overweight and smoking).RESULTS It is observed that a normal physical fitness level is sufficient to induce a preventive action on abdominal obesity(38%), diabetes(12%), hypertension(33%), obesity(12%) and overweight(11%). Also, the preventive fraction increases with the level of physical fitness, in particular for hypertension(36%) and overweight(16%). A high physical fitness level does not necessarily induce a preventive action in most risk factors, excluding depression. CONCLUSION This is the first study which demonstrates that reaching a normal physical fitness level is enough to induce a protection for some risk factors, despite having a CVD.     

Relationship between nutrition status and dental occlusion in community‐dwelling frail elderly people

Aim: This study aimed to determine the risk of malnutrition in some communities where the frail elderly receive public long‐term care insurance. We also clarified the dental problems in those at risk of malnutrition. Methods: A total of 716 frail elderly who lived in eight cities in Japan (240 males and 476 females with a mean age of 83.2 ± 8.6 years) were divided into three groups according to Mini Nutritional Assessment short form results: well nourished, at risk of malnutrition and malnourished. They were also divided into three groups in terms of remaining teeth occlusion and denture occlusion: group A, natural dentition with adequate function; group B, partially or fully edentulous, but maintaining functional occlusion with dentures in either or both jaws; and group C, functionally inadequate occlusion with no dentures. The relationship between nutrition status and dental occlusion was evaluated using logistic regression analysis with sex, age, activities of daily living and cognitive function as covariates. Results: The number of participants in each of the groups was as follows: 251 well nourished, 370 at risk of malnutrition and 95 malnourished. When they were divided into just two groups, (i) well nourished and (ii) at risk of malnutrition plus malnourished, in order to study malnutrition risk factors, there were significant relationships between their nutritious status and sex, Barthel index, and occlusion. Conclusion: This large‐scale cross‐sectional survey showed that loss of natural teeth occlusion was a risk factor for malnutrition among community‐dwelling frail elderly. Geriatr Gerontol Int 2013; 13: 50–54 .     

Examination of validity of fall risk assessment items for screening high fall risk elderly among the healthy community-dwelling Japanese population

We aimed to examine the validity of fall risk assessment items for the healthy community-dwelling elderly Japanese population. Participants were 1122 healthy elderly individuals aged 60 years and over (380 males and 742 females). The percentage who had experienced a fall was 15.8%. This study used fall experience and 50 fall risk assessment items representing the five risk factors (symptoms of falling, physical function, disease and physical symptom, environment, and behavior and character), as we described before. The accuracy of predicting fall experience from the total score or each risk factor score was examined by discriminant analysis. The percentage correctly distinguishing the faller from the total score was 14.4%, and that from the five risk factor scores was 39.7%. This percentage, when using each risk factor score as an independent variable, was 42.5% (symptom of falling), 0.6% (physical function score), 0.6% (disease and physical symptoms score), 0.0% (environment score), and 1.1% (behavior and character score), respectively. The best predictor of fall experience of the community-dwelling elderly was the “symptom of falling” score. For fall risk assessment of the community-dwelling elderly, both of screening of fall risk level and assessing risk profile comprehensively is important.     

Pain, physical performance and balance in the elderly at hospital

This study was aimed to determine the pain, physical performance and balance conditions of the elderly hospitalized in university hospital geriatric wards. The reasons for hospitalization and co-morbid diseases were recorded. Severity of pain was assessed on a visual analogue scale. Activity independence ability was tested by physical performance test (PPT). Tinetti balance and gait evaluation scale (GES) were used to assess balance. Fifty patients (54%) had reported any kind of pain. Mean score for PPT was 13.32 ± 6.56 and for Tinetti test was 9.76 ± 3.8. The correlation between pain, physical performance and balance for 93 patients, 65 years and above was analyzed and not found statistically significant. We believe that pain can affect physical performance and balance. Therefore, it should be carefully evaluated in every elderly patient. Further studies are necessary to investigate the relationship between pain, physical performance and balance of elderly hospitalized patients.     

Six-year prospective study of physical fitness and incidence of disability among community-dwelling Japanese elderly women

Aim:   To identify physical fitness factors associated with occurrence of disability requiring long-term care and reviewing physical fitness factors to identify threshold values at which future care risk is expected to rise rapidly.
Methods:   This prospective cohort study included 74–88-year-old women who were living at home and who reported no disability in activities of daily living. The subjects completed 16 physical fitness tests, assessing walking ability, muscular strength, flexibility, agility and balance, and participated in a follow-up interview 6 years later.
Results:   Among the 60 subjects who were not disabled at baseline and who participated in the 6-year follow up, 28 subjects were certified to have a disability necessitating long-term care after 6 years. Among the 16 physical fitness tests, 13 measures showed a significant association with the necessity of care. Maximum walking time and ankle dorsiflexion range of motion (ROM) were identified as main physical fitness factors associated with later necessity of care using a multiple logistic regression model. After adjustment for age, each subject's probability of occurrence of disability necessitating care was calculated using a logistic equation. The probability rose rapidly to more than 80% when 10 m maximum walking of 74–78-year-old subjects was 10 s. For 80–88-year-old subjects, the probability rose rapidly to more than 80% when the time was at 9 s. As ankle dorsiflexion ROM narrowed, the probability rose gradually.
Conclusion:   Ability to walk rapidly is an indicative main physical fitness marker for predicting the independence of elderly women.     

Influence of history of smoking on the physical capacity of older people

Among the elderly, smoking is related to death and it contributes to disability associated with chronic diseases. This study aims to verify the influence of a history of smoking on the physical capacity of elderly people, and its relationship with the gender. Elderly people beginning to practice physical activity reported questions about their smoking history and underwent a physical evaluation, consisted by hemodynamic data (blood pressure, heart rate and maximum oxygen consumption), body mass index (BMI), muscular strength, flexibility and balance. Mann-Whitney test and Spearman's test was used to data analysis. The sample consisted of 127 subjects, among whom 26.8% were ex-smokers. There were a higher number of nonsmoking women (p < 0.001) than others, and women smoked fewer packets per day (p = 0.047). Among the women, those ex-smokers were younger and more flexible in comparison with those nonsmokers (p < 0.05). Among the men, the ex-smokers were older and walked more slowly than nonsmokers (p < 0.05). There was a correlation between the BMI and duration of smoking time. Smoking cessation benefits the elderly, since the physical variables showed no long-term harm associated with the history of smoking when compared with those of elderly without this habit.     

Studies of impact on physical fitness and working capacity of patients with advanced Schistosomiasis japonica in Susong County,Anhui Province

To assess the impact level on physical fitness and working capacity in patients with advanced Schistosomiasis japonica, a field study was carried out. According to the records of patients with advanced schistosomiasis in Susong County, Anhui Province, 48 advanced cases without other serious chronic diseases from endemic areas in two townships and 56 healthy individuals from non-endemic area, served as control group with matched ages between 40 and 70 years and matched sex were investigated with questionnaire, anthropometric measure and hemoglobin level. The impairment level of the liver was measured by ultrasonography and physical fitness was measured by the Step test in the case and control groups. All situations including lifestyle, working, socio-economic status and residing environment was similar in the case and control groups. Average height and weight was significantly lower in the case group than in the control group (height = 156.29 and 159.41 cm; weight = 50.72 and 53.92 kg; respectively, all P < 0.05). Thirteen individuals (28.3%) in the case group had moderate reduction of working capacity or even unable to work, but only seven (12.7%) individuals in the control group had moderate reduction of working capacity and all in the control group were able to work (P < 0.01). In the past 1 year, the average working days lost was 4.11 days in the case group and 0.86 day in the control group (P < 0.01). Both groups differed significantly in symptoms of abdominal pain, diarrhea and weakness (all P < 0.05). Twenty-one cases (43.8%) had grade II impairment of the liver and eight cases (16.7%) had grade III impairment of the liver in the case group, whereas seven individuals (12.7%) had grade II impairment of the liver in the control group (P < 0.01), as assessed by ultrasound. The hemoglobin levels and the power of gripping in the case group were significantly lower than those in the control group (Hb = 111.06 and 122.27 g/l; grip = 303.83 and 344.20 N, respectively, all P < 0.01). Physical fitness scores showed the control group (score: 71.84) was significantly fitter than the case group (score: 61.09, P < 0.01). Compared with the control group, the physical fitness of the case group reduced by 15%. The results showed that physical fitness and working capacity were reduced in advanced cases. Although most of the cases were treated and had reached a status of 'clinical cure', the impact on physical fitness and working capacity still existed.     

Comparison of the physical fitness levels in nursing home residents and community-dwelling older adults

PurposeThis study aimed to compare the physical fitness levels of nursing home residents and community-dwelling older adults.Materials and methodsThe 118 older adults aged between 65–85 living in a nursing home or community participated in the study. The Senior Fitness Test assessed the physical fitness levels of older adults. The older adults performed the chair stand test, arm curl test, 2-min step test, chair sit and reach test, back-scratch test, 8-foot up, and go test.ResultsThe age, cognitive status, gender, body weight, height, smoking, and education status were similar between the groups (p > 0.05). Aerobic endurance, balance, and agility were higher in nursing home residents than in the community-dwelling older adults (p < 0.05). Strength, flexibility, and BMI did not differ between groups ​​(p > 0.05).ConclusionAerobic endurance, balance, and agility may vary depending on the living environment of older adults. The determination of differences in physical fitness between community-dwelling older adults and nursing home residents could provide objective information to develop a physical activity program for older adults.     

Frailty,physical function and affective status in elderly patients on hemodialysis

ObjetivesTo analyze depression, cognition, and physical function change in older adults on hemodialysis at 12-month follow-up, depending on frailty status.DesignOngoing cohort study.Participants117 patients older than 69 years on hemodialysis; 75 men.MeasurementsFrailty was measured with the frailty phenotype, disability in basic and instrumental activities of daily living with the Barthel and Lawton index respectively, physical function with the Short Physical Performance Battery (SPPB), cognitive status with the Mini Cognitive Examination, and depression with the Yesavage´s Geriatric Depression Scale (GDS), at hemodialysis initiation and after 12-month follow-up. Inflammatory and nutrition profile was determined with C-reactive protein (CRP), albumin, and haemoglobin levels.ResultsThe mean age of the participants was 78.1 years; 63 (53.8 %) were frail. Frail participants had a higher 12-month mortality risk compared to the non frail ones, hazard ratio 2.6 (95 % CI 0.9–7.9). Frail 12-month survivors presented an improvement in median GDS scores (10 to 9; p = .009). There was no change in frail survivors from SPPB ≤ 6 to SPPB > 6 and a shift in 29.3 % of non-frail survivors from SPPB > 6 to SPPB ≤ 6 (p = .007) after 12-month follow-up. Median CRP and haemoglobin levels improved in frail 12-month survivors from 13.9 to 8.3 mg/dL (p = .019) and 9.9–11.1 g/dL (p < .001) respectively.ConclusionsFrail older adults that initiate hemodialysis present higher mortality than the non-frail ones at 12-month follow-up. Frail patients that survive improve physical function, depression and inflammatory profile compared to the non frail ones.     

Cognitive performance as a predictor of functional decline among the non-disabled elderly dwelling in a Japanese community: a 4-year population-based prospective cohort study

This study longitudinally examined the relationships between the specific domains of cognitive performance and functional decline among the community elderly. The study population was 119 men and 194 women aged 70-84 at baseline, who were examined at both baseline and in a 4-year follow-up survey. Katz's Index and the Tokyo Metropolitan Institute of Gerontology Index of Competence (TMIG-IC) were used for measuring the functional capacities of basic activities of daily living (BADL) and higher-level competence, respectively. For the purpose of analyses, declines in each subscale of functional capacity during the follow-up period were used as outcome variables; and specific domains of cognitive performances, including information processing speed, executive function, orientation, and episodic memory at baseline, were used as independent variables. Multiple logistic regression analyses, adjusted for the potential confounders, showed that information processing speed and orientation were associated independently and inversely with BADL decline, and that information processing speed and executive function were related independently and inversely to higher-level competence decline. These results suggested that information processing speed and orientation are reliable predictors for decline in BADL, and information processing speed and executive function are also reliable predictors for decline in higher-level competence among the community elderly.