What Is the Relation Between Fear of Falling and Physical Activity in Older Adults?

Objective

To describe the association between fear of falling (FOF) and total daily activity in older adults.

Design

Cross-sectional observational study.

Setting

Ambulatory clinical research training center.

Participants

Community-dwelling older adults aged ≥64 years (N=78), who were independent in ambulation with or without an assistive device.

Interventions

Not applicable.

Main Outcome Measures

FOF was defined by self-reported fear ratings using the Survey of Activities and Fear of Falling in the Elderly and self-reported fear status determined by response to the following question: Are you afraid of falling? Physical function was assessed using the Late Life Function and Disability Instrument. Physical activity was recorded using an accelerometer worn on the waist for 7 consecutive days, and mean daily counts of activity per minute were averaged over the 7-day period.

Results

Fear ratings were related to total daily activity (r=−.26, P=.02). The relation was not as strong as the relation of function and physical activity (r=.45, P<.001). When stratified by exercise status or functional status, fear was no longer related to total daily activity. Physical function explained 19% of the variance in physical activity, whereas the addition of fear status did not add to the explained variance in physical activity.

Conclusions

FOF is related to total daily physical activity; however, FOF was not independently associated with physical activity when accounting for physical function. Some FOF may be reported as a limitation in function.     

“Age-Related Positivity Effect” in the Relationship Between Pain and Depression Among Chinese Community-Dwelling Older Adults: Sex Differences

PurposeTo examine the “age-related positivity effect” and its sex differences in the pain-depression relationship among Chinese community-dwelling older adults.DesignCross-sectional design.MethodsThe study was conducted with a sample of 1,913 older adults in Jinan, China. Data were collected on pain intensity, age, sex, depressive symptoms, and potential covariates.ResultsThe hierarchical linear regression analyses revealed that pain intensity was significantly related to depressive symptoms, there was a significant two-way interaction between age and pain intensity, and there was a significant three-way interaction between sex, age, and pain intensity. The Johnson-Neyman plot revealed that the relationship between pain and depressive symptoms decreased with advancing age, indicating an “age-related positivity effect.” And the age-related positivity effect in the pain-depression relationship was significant only in men, but not in women.ConclusionsThe study suggests that all older women and “young-old” men (younger senior citizens aged 60-79) in China are more likely to experience depressive symptoms from pain. Interventions on cognitive psychology should particularly target all older women and young-old men to reduce the detrimental effect of pain on emotional well-being.     

Which Neuromuscular Attributes Are Associated With Changes in Mobility Among Community-Dwelling Older Adults With Symptomatic Lumbar Spinal Stenosis?

Objectives

To identify neuromuscular attributes associated with mobility and changes in mobility over 2 years of follow-up among patients with and without symptomatic lumbar spinal stenosis (SLSS).

Memory Performance and Affect: Are there Gender Differences in Community-Residing Older Adults?

After age 65, the incidence of episodic memory decline in males is greater than in females. We explored the influence of anxiety and depression on objective and subjective memory performance in a diverse sample of community-residing older adults. The study was a secondary analysis of data on three samples of adults from two states, Ohio and Texas: a community sample (n = 177); a retirement community sample (n = 97); and the SeniorWISE Study (n = 265). The sample of 529 adults was 74% female, the average age was 76.58 years (range = 59–100 years), and educational attainment was 13.12 years (±3.68); 68% were Caucasian, and 17% had depressive symptoms. We found no memory performance differences by gender. Males and females were similarly classified into the four memory performance groups, with almost half of each gender in the poor memory category. Even though males had greater years of education, they used fewer compensatory memory strategies. The observed gender differences in memory were subjective evaluations, specifically metamemory. Age was not a significant predictor of cognition or memory performance, nor did males have greater memory impairment than females.     

What is the Evidence and Context for Implementing Family-Centered Care for Older Adults?

ABSTRACT

Aims: This project used the Promoting Action on Research Implementation in Health Services (PARIHS) knowledge translation framework to better understand the evidence and context for implementing family-centered care for older adults in rural home-based rehabilitative practices. Methods: A case-study design with multiple data collection methods was used to examine rural home-based rehabilitative care for older adults and their caregivers within one provincial healthcare system. Results: The study findings indicated therapists questioned whether their scope of practice should include addressing caregiver needs outside of implementing the therapist's care plan for the client. Therapists also confirmed that multiple contextual levels influence the provision of family-centered care. Conclusions: The PARIHS framework made it easier for the academic and non-academic partners to collaborate; furthermore, the framework identified that the practitioner's clinical experience is an essential component to evaluating and implementing evidence into practice.     

Community Ambulation in Older Adults: Which Internal Characteristics Are Important?

Lord SE, Weatherall M, Rochester L. Community ambulation in older adults: which internal characteristics are important?

Objective

To examine the internal characteristics of older adults independent in community ambulation to gain further understanding of the skills required for its successful execution.

Design

Exploratory factor analysis.

Setting

General community.

Participants

Healthy, community dwelling older adults (N=113) who were cognitively intact and walked outdoors independently.

Interventions

Not applicable.

Main Outcome Measures

Spatiotemporal gait parameters derived from accelerometry over 6 minutes walking outdoors and a battery of measures for motor, cognitive, executive, and behavioral characteristics.

Results

Mean participant age ± SD was 75.8±7.3 years, with almost a third of the sample over 80 years. Four factors emerged from the Factor Analysis of 23 variables: motor control, self-efficacy, executive function, and cognitive-motor interference, which together explained 61.4% of common variance. Eight variables loaded onto motor control, accounting for 34.5% of common variance; 7 items loaded onto self-efficacy, which explained 12.4% of common variance; 5 variables loaded onto executive function, accounting for 8.4% of common variance; and 3 variables loaded onto cognitive-motor interference, explaining 6% of the variance.

Conclusions

Results of this study indicate that factors beyond motor control contribute to independent community ambulation in older adults, reflecting the multidimensional, complex nature of the task. Self-efficacy was shown to be more relevant than executive function to gait performance, suggesting the need for a broader approach to assessment and intervention strategies.     

What is the Relationship Between Fear of Falling and Gait in Well-Functioning Older Persons Aged 65 to 70 Years?

Rochat S, Büla CJ, Martin E, Seematter-Bagnoud L, Karmaniola A, Aminian K, Piot-Ziegler C, Santos-Eggimann B. What is the relationship between fear of falling and gait in well-functioning older persons aged 65 to 70 years?

Objective

To investigate the association between fear of falling and gait performance in well-functioning older persons.

Design

Survey.

Setting

Community.

Participants

Subjects (N=860, aged 65-70y) were a subsample of participants enrolled in a cohort study who underwent gait measurements.

Interventions

Not applicable.

Main Outcome Measures

Fear of falling and its severity were assessed by 2 questions about fear and related activity restriction. Gait performance, including gait variability, was measured using body-fixed sensors.

Results

Overall, 29.6% (210/860) of the participants reported fear of falling, with 5.2% (45/860) reporting activity restriction. Fear of falling was associated with reduced gait performance, including increased gait variability. A gradient in gait performance was observed from participants without fear to those reporting fear without activity restriction and those reporting both fear and activity restriction. For instance, stride velocity decreased from 1.15±.15 to 1.11±.17 to 1.00±.19 m/s (P<.001) in participants without fear, with fear but no activity restriction and with fear and activity restriction, respectively. In multivariate analysis, fear of falling with activity restriction remained associated with reduced gait performance, independent of sex, comorbidity, functional status, falls history, and depressive symptoms.

Conclusions

In these well-functioning older people, those reporting fear of falling with activity restriction had reduced gait performance and increased gait variability, independent of health and functional status. These relationships suggest that early interventions targeting fear of falling might potentially help to prevent its adverse consequences on mobility and function in similar populations.     

What Constitutes a Good and Bad Death?: Perspectives of Homeless Older Adults

This qualitative study explored perspectives toward a good or bad death among 21 older homeless adults residing in transitional housing. Using grounded theory approach, the themes for a good death were (a) dying peacefully; (b) not suffering; (c) experiencing spiritual connection; and (d) making amends with significant others. Themes for a bad death were (a) experiencing death by accident or violence; (b) prolonging life with life supports; (c) becoming dependent while entering a dying trajectory; and (d) dying alone. Healthcare professionals need to develop approaches for end-of-life care grounded in understanding unique needs of older homeless adults.     

Procedural Sedation and Analgesia in the Emergency Department: What Are the Risks?

The practitioner of emergency medicine is routinely faced with patients in need of emergent procedures and pain control and sedation. Our challenge is to make our patients' experiences as painless and as safe as possible, while maximizing our ability to perform the procedure at hand; this is not always an easy task given the propensity of each human body to react differently to interventions and stimuli. We can best meet this challenge by understanding how our patients and pharmaceutical agents intermingle in the risk-benefit equation we formulate before starting our "experiment." Coupling this information with fundamentally sound patient care and monitoring will minimize bad experiences with PSA for both the patient and practitioner.     

Differentiating Symptoms of Anxiety and Depression in Older Adults: Distinct Cognitive and Affective Profiles?

Cognitive and affective dimensions of symptomsof anxiety and depression were examined in a sample of283 community-dwelling older adults (ranging in age from65 to 93 years). A principal-axis factor analysis with varimax rotation conducted on theCognition Checklist (CCL) revealed a factor structuredifferent than that found in younger adults. Threefactors emerged (Anxious, Social Loss, and NegativeSelf-Evaluation/Worthlessness Cognitions) and, in general, these cognitionswere not specifically related to anxious and depressivesymptoms. Instead, worthlessness cognitions wererobustly associated with both anxious and depressive symptoms, including variance that was unique toeach. In terms of affective dimensions, factor analysesrevealed that only anxiety-related items loaded on thenegative affectivity subscale. Consequently, negative affectivity was strongly related tovariance that was unique to anxious symptoms, but wasonly weakly related to variance that was unique todepressive symptoms. On the other hand, positiveaffectivity was only weakly associated with both forms ofsymptomatology. Findings are discussed in terms of thecognitive and affective distinctions between older andyounger adulthood.     

Do Predictive Relationships Exist Between Postural Control and Falls Efficacy in Unilateral Transtibial Prosthesis Users?

Objective

To assess whether variables from a postural control test relate to and predict falls efficacy in prosthesis users.

Is Highly Challenging and Progressive Balance Training Feasible in Older Adults With Parkinson's Disease?

Objective

To develop a highly challenging and progressive group balance training regime specific to Parkinson's disease (PD) symptoms and to investigate its feasibility in older adults with mild to moderate PD.

Design

Intervention study, before-after trial with a development and feasibility design.

Setting

University hospital setting.

Participants

Feasibility was evaluated in older adults (N=5; mean age, 72y; age range, 69–80y) with mild to moderate idiopathic PD.

Intervention

A balance training regime emphasizing specific and highly challenging exercises, performed 3 times per week for 12 weeks, was developed through discussion and workshops by a group of researchers and physiotherapists.

Main Outcome Measures

Indicators of feasibility included attendance rate, safety (adverse events, physical function, and pain), participants' perceptions of the intervention (level of difficulty of the exercises, motivation level, and appreciation), and efficacy of the intervention (balance performance assessed with the Mini-Balance Evaluation Systems Test [Mini-BESTest]).

Results

The incidence rate was high (93%) for attendance and low (1.2%) for adverse events. Ratings by the participants indicated progression throughout the training period. All participants considered the training motivational and stated that they would recommend it to others. The efficacy of the intervention measured with the Mini-BESTest showed that 4 out of 5 participants improved their balance performance.

Conclusions

These findings support the overall feasibility of this novel balance program in older adults with mild to moderate PD. However, to further evaluate the efficacy of the program, a larger randomized controlled trial is required.     

Assessment of the Right Ventricle in Adults: What Have the Guidelines Taught Us?

In the last decade, the role of the right ventricle (RV) has been increasingly recognized in a variety of conditions, contributing to the pathophysiology of disease and the prediction of outcomes. Recent echocardiography guidelines focused on the RV have been published by the American Society of Echocardiography to encourage a standardized approach in assessing RV size and function. In this article, we review the recently published echocardiography guidelines for assessing RV size and function, and their importance in clinical practice. We discuss advantages and disadvantages of currently available imaging techniques for evaluating the RV morphology, size, and systolic function. Basic methods such as TAPSE, tissue Doppler, RIMP, and fractional area change are discussed, as are more emerging techniques such as strain and strain rate. Additional insights are provided into upcoming uses of echocardiography in the areas or RV dyssynchrony and three-dimensional echocardiography.     

Elevated HbA1c and Fasting Plasma Glucose in Predicting Diabetes Incidence Among Older Adults: Are two better than one?

OBJECTIVE

To determine which measures—impaired fasting glucose (IFG), elevated HbA_1c, or both—best predict incident diabetes in older adults.

RESEARCH DESIGN AND METHODS

From the Health, Aging, and Body Composition study, we selected individuals without diabetes, and we defined IFG (100–125 mg/dL) and elevated HbA_1c (5.7–6.4%) per American Diabetes Association guidelines. Incident diabetes was based on self-report, use of antihyperglycemic medicines, or HbA_1c ≥6.5% during 7 years of follow-up. Logistic regression analyses were adjusted for age, sex, race, site, BMI, smoking, blood pressure, and physical activity. Discrimination and calibration were assessed for models with IFG and with both IFG and elevated HbA_1c.

RESULTS

Among 1,690 adults (mean age 76.5, 46% men, 32% black), 183 (10.8%) developed diabetes over 7 years. Adjusted odds ratios of diabetes were 6.2 (95% CI 4.4–8.8) in those with IFG (versus those with fasting plasma glucose [FPG] <100 mg/dL) and 11.3 (7.8–16.4) in those with elevated HbA_1c (versus those with HbA_1c <5.7%). When FPG and HbA_1c were considered together, odds ratios were 3.5 (1.9–6.3) in those with IFG only, 8.0 (4.8–13.2) in those with elevated HbA_1c only, and 26.2 (16.3–42.1) in those with both IFG and elevated HbA_1c (versus those with normal FPG and HbA_1c). Addition of elevated HbA_1c to the model with IFG resulted in improved discrimination and calibration.

CONCLUSIONS

Older adults with both IFG and elevated HbA_1c have a substantially increased odds of developing diabetes over 7 years. Combined screening with FPG and HbA_1c may identify older adults at very high risk for diabetes.Impaired fasting glucose (IFG) (100–125 mg/dL) has been traditionally used for identifying persons at high risk for the subsequent development of diabetes in the U.S. Recent guidelines have additionally endorsed the use of HbA_1c 5.7–6.4% to identify those at risk (1). However, multiple studies, including one conducted among older persons (2), suggest that HbA_1c may identify different individuals at risk for diabetes than traditional glucose measures (3–6). Although several recent investigations confirm that HbA_1c is strongly predictive of future diabetes in predominantly middle-aged populations (7–10), less is known about how well HbA_1c identifies older persons at risk for diabetes.Despite the high prevalence of type 2 diabetes in the elderly (10.9 million Americans in 2010) and the high incidence (390,000 new cases in 2010) of late-onset type 2 diabetes (>65 years) (11,12), there are few specific studies on prediction of diabetes in this group. One such study, based on an earlier Health, Aging, and Body Composition (Health ABC) analysis, developed a prediction rule for diabetes development, which included several factors: advanced age, female sex, elevated fasting plasma glucose (FPG), and triglyceride levels (13). However, HbA_1c was not examined as a potential predictor. In the Cardiovascular Health Study of men and women ≥65 years of age, BMI, waist-to-hip ratio, and weight gain were associated with a higher risk of diabetes, but the impact of glycemic measures on diabetes was not specifically examined (14). An Italian study of older adults (age 65–84 years) found that the combination of abnormal FPG (defined using World Health Organization [WHO] criteria: 110 to <126 mg/dL), increased waist circumference, and HbA_1c ≥7.0% increased the probability of incident diabetes roughly 14-fold (15). However, neither a direct comparison of current prediabetes categories (based upon FPG and HbA_1c) for prediction of diabetes nor an analysis of the utility of combined testing has previously been conducted in this population.We therefore evaluated the odds for diabetes based upon baseline IFG and elevated HbA_1c among the participants of the longitudinal Health ABC study. We directly compared FPG- and HbA_1c-based criteria for predicting the eventual development of diabetes, and we evaluated the utility of combined testing for identifying older persons who develop diabetes. Since HbA_1c values are consistently higher in blacks compared with whites (3,16), we additionally explored race differences in diabetes prediction.     

What Are We Missing in the Diagnostic Criteria for Migraine?

Purpose of Review

This review is intended to examine how the diagnostic criteria for migraine have evolved over the past 45 years and to evaluate the strengths and weaknesses of the current diagnostic criteria promulgated by the International Classification of Headache Disorders (ICHD).

Recent Findings

The ICHD is a comprehensive and systematic classification system for headache disorders. As the pathophysiology of migraine is more fully elucidated and more sophisticated diagnostic technologies are developed (e.g., the identification of biomarkers), the current diagnostic criteria for migraine will likely be further refined. The ICHD has allowed for more precise research study design in the field of headache medicine.

Summary

The current diagnostic criteria for migraine outlined in the 3rd version of the ICHD are far more sensitive and specific than the clinical criteria proposed in 1962. In future iterations, dividing episodic and chronic migraine into subtypes based on frequency (i.e., low frequency vs high frequency; near-daily vs daily) potentially could assist in guiding clinical management. In addition, a better understanding of aura, vestibular migraine, migrainous infarction, and hemiplegic migraine likely will lead to more refined diagnostic criteria for those entities.

     

Coronary Artery Calcification in Obese Youth: What Are the Phenotypic and Metabolic Determinants?

OBJECTIVE

Obesity in adolescence has been associated with increased risk for coronary heart disease in adulthood. This study evaluated subclinical atherosclerosis in obese youth and the underlying risk factors.

RESEARCH DESIGN AND METHODS

Ninety obese adolescents (37 normal glucose tolerant, 27 prediabetes, and 26 type 2 diabetes) underwent evaluation of coronary artery calcifications (CACs) by electron beam computed tomography, aortic pulse wave velocity (PWV), carotid intima-media thickness (IMT), lipids, leptin, inflammatory markers, and body composition (DEXA). A total of 68 underwent evaluation of insulin sensitivity (IS) (hyperinsulinemic-euglycemic clamp) and abdominal adiposity (computed tomography).

RESULTS

A total of 50% had CACs (CAC+: Agatston CAC score ≥1). CAC+ youth had higher BMI, fat mass, and abdominal fat, with no difference in sex, race, IS per fat-free mass (IS_FFM), glucose tolerance, PWV, or IMT compared with the CAC− group. PWV was inversely related to IS. In multiple regression analyses with age, race, sex, HbA_1c, BMI (or waist circumference), IS_FFM, diastolic blood pressure, non–HDL cholesterol, and leptin as independent variables, BMI (or waist) (R² = 0.41; P = 0.001) was the significant determinant of CAC; leptin (R² = 0.37; P = 0.034) for PWV; and HbA_1c, race, and age (R² = 0.34; P = 0.02) for IMT.

CONCLUSIONS

Early in the course of obesity, there is evidence of CAC independent of glycemia. The different biomarkers of subclinical atherosclerosis appear to be differentially modulated, adiposity being the major determinant of CAC, hyperglycemia, age, and race for IMT, and leptin and IS for arterial stiffness. These findings highlight the increased cardiovascular disease risk in obese youth and the need for early interventions to reverse obesity and atherosclerosis.