Disability in older adults. 2: Physical activity as prevention

Effects of a Multicomponent Exercise and Therapeutic Lifestyle (CERgAS) Intervention on Gait Function in Lower-Income Urban-Dwelling Older Adults: A Cluster Randomized Controlled Trial

This study aims to determine the effectiveness of a multicomponent exercise and therapeutic lifestyle (CERgAS) intervention at improving gait speed among older people in an urban poor setting in Malaysia. A total of 249 participants were divided into the intervention (n = 163) and control (n = 86) groups. The mean (SD) age of participants was 67.83 (6.37) and consisted of 88 (35.3%) males and 161 (64.7%) females. A generalized estimating equation with an intention-to-treat analysis was used to measure gait speed at four time points, baseline (T0), 6 weeks (T1), 3 months postintervention (T2), and 6 months postintervention (T3). The results showed significant changes for time between T0 and T3 (mean difference = 0.0882, p = .001), whereas no significant association were found for group (p = .650) and interaction (p = .348) effects. A 6-week intervention is inadequate to improve gait speed. Future efforts should introduce physical activity monitoring and increase exercise duration, frequency, and intensity.

Application of the Transtheoretical Model to Identify Physical Activity-Related Psychological Variables in Disabled Adults

OBJECTIVES The current study aimed at identifying the theoretical relation of the transtheoretical model (TTM) to explain physical activity in Korean adults with physical disabilities.METHODS A total of 194 participants ( Age Mean = 48.65 years) were voluntarily recruited for this study. Dissemination sources for participant recruitment included: (a) a press release issued through the authors’ university; (b) recruitment flyers posted on various websites (e.g., Independent Living Centers, Rehabilitation Research and Training Centers, Veteran’s Administration Hospitals); and (c) announcements made through and in conjunction with the Rehabilitation Research and Training Center on Health and Wellness consortium members. Through these procedures, 194 adults (80.83%) completed the survey form; there were 113 males (58.3%) and 81 females (41.7%). The remaining 46 (19.17%) were excluded because they did not complete the survey form or return.RESULTS Results indicated that the TTM constructs assessed were significantly (P < 0.001) associated with the stages of change for physical activity. The largest portion of variance was derived from the behavioral processes of change (ƞ2 = .40), followed by self-efficacy (ƞ2 = .30), the pros for exercise (ƞ2 = .19), the cognitive processes of change and the cons for exercise (ƞ2 = .16, respectively). Moreover, four discriminant functions (i.e., composite scores of the predictors) were produced in the first DDF analysis. These accounted for 71.0% (Wilks’ Λ = .31, χ2 [56] = 368.04, P < .001), 20.9% (Wilks’ Λ = .66, χ2 [39] = 129.91, P < 0.001), 6.3% (Wilks’ Λ = .88, χ2 [24] = 39.39, P < 0.05), and 1.8% (Wilks’ Λ = .97, χ2 [11] = 9.04, P = .62), respectively, of the between-group (stage of change) variability.CONCLUSIONS The results provide further cross-sectional support for the internal validity of the transtheoretical model, as the processes of change, self-efficacy, and decisional balance were important variables of a stage of change for physical activity, Additionally, the study is in general agreement with existing evidence among nondisabled populations and, therefore, it supports the external validation of TTM to a unique and understudied population segment.

An Interactive Physical-Cognitive Game-Based Training System Using Kinect for Older Adults: Development and Usability Study

BACKGROUND

Declines in physical and cognitive functions are recognized as important risk factors for falls in older adults. Promising evidence suggests that interactive game-based systems that allow simultaneous physical and cognitive exercise are a potential approach to enhance exercise adherence and reduce fall risk in older adults. However, a limited number of studies have reported the development of a combined physical-cognitive game-based training system for fall risk reduction in older adults.

OBJECTIVE

The aim of this study is to develop and evaluate the usability of an interactive physical-cognitive game-based training system (game-based exercise) for older adults.

METHODS

In the development phase (Part I), a game-based exercise prototype was created by integrating knowledge and a literature review as well as brainstorming with experts on effective fall prevention exercise for older adults. The output was a game-based exercise prototype that covers crucial physical and cognitive components related to falls. In the usability testing (Part II), 5 games (ie, Fruits Hunter, Where Am I?, Whack a Mole, Sky Falls, and Crossing Poison River) with three difficulty levels (ie, beginner, intermediate, and advanced levels) were tested in 5 older adults (mean age 70.40 years, SD 5.41 years). After completing the games, participants rated their enjoyment level while engaging with the games using the Physical Activity Enjoyment Scale (PACES) and commented on the games. Descriptive statistics were used to describe the participants' characteristics and PACES scores.

RESULTS

The results showed that the average PACES score was 123 out of 126 points overall and between 6.66 and 7.00 for each item, indicating a high level of enjoyment. Positive feedback, such as praise for the well-designed interactions and user-friendly interfaces, was also provided.

CONCLUSIONS

These findings suggest that it is promising to implement an interactive, physical-cognitive game-based exercise in older adults. The effectiveness of a game-based exercise program for fall risk reduction has yet to be determined.

Minority Women

Perceptions of illness, pain, and death are not static. They vary among populations according to their cultural and biological characteristics. Older black and Hispanic/Latinx women are unique in their approach to health care with respect to mentation, mobility, medication adherence, and what matters to them. It is the complexity of these components, which affect the ability of these women to age gracefully.

Aspects of exercise with person-centred guidance influencing the transition to independent exercise: a qualitative interview study among older adults with rheumatoid arthritis

Background

Besides being health enhancing and disease preventing, exercise is also an important part of the management of chronic conditions, including the inflammatory joint disease rheumatoid arthritis (RA). However, older adults with RA present a lower level of physical activity than healthy older adults. The aim of this qualitative study was to explore aspects of participation in moderate- to high-intensity exercise with person-centred guidance influencing the transition to independent exercise for older adults with RA.

Methods

A qualitative interview study was conducted. In-depth interviews with 16 adults with RA aged between 68 and 75 years, who had taken part in the intervention arm of a randomized controlled trial performing moderate- to- high-intensity exercise with person-centred guidance, were analysed using qualitative content analysis.

Results

The analysis resulted in six main categories: A feasible opportunity to adopt exercise, Experiencing positive effects of exercise, Contextual factors affect the experience of exercise, Developing knowledge and thinking, Finding one’s way, and Managing barriers for exercise. The exercise with person-centred guidance was described as a feasible opportunity to start exercising as a basis for the transition to independent exercise. They described developing knowledge and thinking about exercise during the intervention enabling them to manage the transition to independent exercise. Finding one’s own way for exercise became important for sustaining independent exercise. Lastly, barriers for exercise and strategies for overcoming these were described. Reduced physical health, both temporary and permanent, was described as a considerable barrier for exercise.

Conclusion

The participants described several aspects of participating in exercise that influenced and facilitated their transition to independent exercise. The exercise was experienced as manageable and positive, by a careful introduction and development of an individual exercise routine in partnership with a physiotherapist. This seems to have favored the development of self-efficacy, with importance for future independent exercise. Reduced physical health, both temporary and permanent, was described as a considerable barrier for exercise. The personal process of trying to make the exercise one’s own, and developing knowledge about exercise and new thoughts about oneself, seemed to prepare the participants for managing independent exercise and overcoming barriers.

Effect of Tai Chi Exercise on Balance Function of Stroke Patients: A Meta-Analysis

Background

Tai Chi is an ancient form of physical activity that has been shown to improve cardiovascular function, but to date there had been no comprehensive systematic review on the effect of Tai Chi exercise on balance function of patients with stroke. This study evaluated the effect of Tai Chi exercise on balance function in stroke patients.

Material/Methods

PubMed, Cochrane library, and China National Knowledge Information databases and the Wan Fang medical network were searched to collect the articles. The random-effects model was used to assess the effect of Tai Chi exercise on balance function of stroke patients.

Results

Six studies were chosen to perform the meta-analysis according to the inclusion and exclusion criteria. There were significant improvements of balance on Berg Balance Scale score (MD=4.823, 95% CI: 2.138–7.508), the standing balance with fall rates (RR=0.300, 95%CI: 0.120–0.770), functional reach test and dynamic gait index in Tai Chi intervention group compared to the control intervention group. However, the short physical performance battery for balance (SPBB) showed Tai Chi did not significantly improve the ability of balance for stroke patients (MD=0.293, 95%CI: −0.099~0.685).

Conclusions

Tai Chi exercise might have a significant impact in improving balance efficiency by increasing BBS score and reducing fall rate.

Influence of combined physical and cognitive training on cognition: a systematic review

BACKGROUND

Numerous daily activities require simultaneous application of motor and cognitive skills (dual-tasking). The execution of such tasks is especially difficult for the elderly and for people with (neuro-) degenerative disorders. Training of physical and cognitive abilities helps prevent or slow down the age-related decline of cognition. The aim of this review is to summarise and assess the role of combined physical-and-cognitive-training characteristics in improving cognitive performance and to propose an effective training scheme within the frame of a suitable experimental design.

METHODS

A systematic electronic literature search was conducted in selected databases. The following criteria were compulsory for inclusion in the study: 1. A (Randomized) Controlled Trial (RCT or CT) design; 2. Implementation of combined physical and cognitive training, either simultaneously (dual task) or subsequently - at least one hour per weekly over four weeks or more; 3. Cognitive outcomes as a study's endpoint.

RESULTS

Twenty articles met the inclusion criteria. It appears that either simultaneous or subsequently combined physical and cognitive training is more successful compared to single physical or single cognitive exercise. Training characteristics like length, frequency, duration, intensity and level of task difficulty seem to determine cognitive performance. However, the articles show that cognitive improvement seems to remain somewhat confined to trained cognitive functions rather than generalising to other cognitive or daily-living skills.

CONCLUSION

Due to methodological heterogeneity among studies, results need to be treated with caution. We critically discuss the role of training characteristics and propose a potentially effective training intervention within an appropriate experimental design.

Understanding older adults' usage of community green spaces in Taipei, Taiwan

As the world's population ages, there is an increasing need for community environments to support physical activity and social connections for older adults. This exploratory study sought to better understand older adults' usage and perceptions of community green spaces in Taipei, Taiwan, through direct observations of seven green spaces and nineteen structured interviews. Descriptive statistics from observations using the System for Observing Play and Recreation in Communities (SOPARC) confirm that older adults use Taipei's parks extensively. Our analyses of interviews support the following recommendations for age-friendly active living initiatives for older adults: make green spaces accessible to older adults; organize a variety of structured activities that appeal to older adults particularly in the morning; equip green spaces for age-appropriate physical activity; and, promote the health advantages of green spaces to older adults.

A randomized controlled trial of an automated exercise coach for older adults

OBJECTIVES

To compare the efficacy of a computer-based physical activity program (Embodied Conversational Agent-ECA) with that of a pedometer control condition in sedentary older adults.

DESIGN

Single-blind block-randomized controlled trial stratified according to clinic site and health literacy status.

SETTING

Three urban ambulatory care practices at Boston Medical Center between April 2009 and September 2011.

PARTICIPANTS

Older adults (N = 263; mean age 71.3; 61% female; 63% African American; 51% high school diploma or less).

INTERVENTION

ECA participants were provided with portable tablet computers with touch screens to use for 2 months and were directed to connect their pedometers to the computer using a data cable and interact with a computer-animated virtual exercise coach daily to discuss walking and to set walking goals. Intervention participants were then given the opportunity to interact with the ECA in a kiosk in their clinic waiting room for the following 10 months. Control participants were given a control pedometer intervention that only tracked step counts for an equivalent period of time. Intervention participants were also provided with pedometers.

MEASUREMENTS

The primary outcome was average daily step count for the 30 days before the 12-month interview. Secondary outcomes were average daily step count for the 30 days before the 2-month interview. Outcomes were also stratified according to health literacy level.

RESULTS

ECA participants walked significantly more steps than control participants at 2 months (adjusted mean 4,041 vs 3,499 steps/day, P = .01), but this effect waned by 12 months (3,861 vs 3,383, P = .09). For participants with adequate health literacy, those in the ECA group walked significantly more than controls at both 2 months (P = .03) and 12 months (P = .02), while those with inadequate health literacy failed to show significant differences between treatment groups at either time point. Intervention participants were highly satisfied with the program.

CONCLUSION

An automated exercise promotion system deployed from outpatient clinics increased walking among older adults over the short-term. Effective methods for long-term maintenance of behavior change are needed.

Physical performance is associated with executive functioning in older african american women

An older adult's ability to perform physical tasks is predictive of disability onset and is associated with declines in cognition. Risk factors for physical performance declines among African Americans, a group with the highest rates of disability, remain understudied. This study sought to identify demographic, health, and cognitive factors associated with lower-extremity physical performance in a sample of 106 African American women ages 56 to 91. After controlling for global cognitive functioning (Mini Mental State Exam), physical performance was associated with executive functioning (Stroop Color/Word), but not visuospatial construction (WASI Block Design) or processing speed (Trail Making Test, Part A). Executive functioning remained associated with physical performance after entry of demographic variables, exercise, depression, disease burden, and body mass index (BMI). Age, and BMI were also significant in this model. Executive functioning, age and BMI are associated with lower-extremity physical performance among older African American women.

The Chronic Illness Context and Change in Exercise Self-Care Among Older Adults: A Longitudinal Analysis

This study examines the stages of change in exercise as a form of coping with chronic illness, among a panel of older adults managing arthritis, cardiovascular disease, or hypertension. Hypotheses connected to socio-demographic, exercise-history, cognitive, and illness contexts are explored in order to advance applications of the Transtheoretical Model for exercise self-care. A random sample of 735 individuals aged 51 to 95, who completed interviews at time 1 (1995–96) and time 2 (1996–97), were drawn from the Vancouver North Shore Self Care Study. Bivariate and hierarchical logistic regression analyses were performed on the data. The descriptive analyses supported two patterns: first, older persons with a chronic illness exhibited a propensity either to remain in or move into the extreme exercise stages (pre-contemplation or maintenance) in a non-sequential manner; second, elements of the illness context were primary determinants of stage of exercise change. Illness type, illness duration, activity restriction, and co-morbidity exhibited associations with exercise-stage change in the multivariate analysis. The findings have a number of direct implications for tailoring health promotion programs targetting older adults, especially those who use exercise as a form of self-care.

Tai Chi exercise and stroke rehabilitation

According to reported global estimates, 15 million people suffer from a stroke each year, resulting in 5.5 million deaths, with 5 million left permanently disabled. Typical disabilities following stroke include poor neuromuscular control, hemodynamic imbalance, and negative mood state. Tai Chi (TC) is associated with better balance, lower blood pressure, and improved mood, which are important for stroke survivors. An overview of the philosophy and principles of TC exercise is provided, followed by a literature review of reported TC studies examining balance, blood pressure, and mood. Finally, the potential application of TC exercise to stroke rehabilitation is discussed.

Effects of a multimodal activation program (SimA-P) in residents of nursing homes

Is it possible to maintain or even enhance functional and cognitive independence in residents of nursing homes? Little is known about the potentials and limits of therapeutic methods designed to maintain independence in elderly people already in need of residential nursing care. The aim of the “Rehabilitation in Nursing Homes” research project was to determine the practicability and effectiveness of a rehabilitative approach targeting residents of nursing homes. The main objectives of the activation program were to maintain and enhance residents’ cognitive and functional autonomy. Data on psychological, functional, and medical variables were obtained from a sample of 294 nursing home residents (age range = 70–99 years) at three points of measurement over a 12-month period. The intervention approach draws on the theoretical and practical findings of the SimA Study (“Bedingungen der Erhaltung und Förderung von Selbstständigkeit im höheren Lebensalter,” “conditions on maintaining and supporting independent living in old age”; Oswald et al., Z. Gerontopsychol. Psychiatr., 15:61–84, 2002, Z. Gerontopsychol. Psychiatr., 15:13–31, 2002) and incorporates the results of recent therapeutic and rehabilitative studies in the fields of geriatrics and gerontopsychiatry. The intervention involves a combined program of cognitive and physical activation. An alternative program based on biographical information was designed specifically for residents with dementia. Results show that the intervention had significant effects on cognitive and functional parameters. Moreover, transfer effects were observed with respect to activities of daily living and frequency of falls.

Morbidity and mortality risk associated with an overweight BMI in older men and women

BACKGROUND

There is controversy as to whether older adults with a BMI in the overweight range (25 to 29.9 kg/m2) are at increased health risk and whether they should be encouraged to lose weight. The purpose of this study was to determine whether older adults with a BMI in the overweight range are at increased morbidity and mortality risk.

METHODS

Participants consisted of 4968 older (>or=65 years) men and women from the Cardiovascular Health Study limited access dataset. Based on BMI (kg/m2), participants were grouped into normal-weight (20 to 24.9 kg/m2), overweight (25 to 29.9 kg/m2), and obese (>or=30 kg/m2) categories. Participants were followed for up to 9 years to determine if they developed 10 weight-related health outcomes that are pertinent to older adults. Cox proportional hazards models were used to estimate the hazards ratios of morbidity and mortality after adjusting for age, sex, income, smoking, and physical activity.

RESULTS

Compared with the normal-weight group, the risks of myocardial infarction, stroke, sleep apnea, urinary incontinence, cancer, and osteoporosis were not different in the overweight group (p>0.05). The risks for arthritis and physical disability were modestly increased in the overweight group (p<0.05), whereas the risk for type 2 diabetes was increased by 78% in the overweight group (p<0.01). After adjusting for all relevant covariates, all-cause mortality risk was 11% lower in the overweight group (p<0.05).

CONCLUSIONS

A BMI in the overweight range was associated with some modest disease risks but a slightly lower overall mortality rate. These findings suggest that a BMI cut-off point of 25 kg/m2 may be overly restrictive for the elderly.

Non pharmacological treatments in elderly diabetics

Among the therapeutic resources available for the elderly diabetic, diet and exercise are often neglected because patients are reluctant to make changes and significant amount of time of healthcare providers and physicians is required for patient education. Diet and exercise work in synergy to lower the biological parameters of diabetes control. Diet in the elderly diabetic patient is based essentially on the nutritional recommendations for the elderly subject, diabetic or non diabetic. Recent studies on exercise demonstrate the value of resistance training in increasing muscle mass, preferably over endurance training. The benefits obtained also involve autonomy and quality of life. Taking up exercise is not devoid of disadvantages because of the frequent co-morbidity at this age.

Differential effects of single versus combined cognitive and physical training with older adults: the SimA study in a 5-year perspective

The present study evaluates the effect of cognitive training, of psychoeducational training and of physical training on cognitive functioning, physical functioning, physical health, independent living and well-being in older people. Also the combination of physical training with cognitive training or psychoeducational training, respectively, was evaluated. In contrast to most training studies with older people, training effects were evaluated in a longitudinal perspective over 5 years to analyse long-term-results of cognitive and physical activity on older adults. Training effects were evaluated compared to a no-treatment-control group. Subjects were 375 community residents aged 75-93 years. Up to 5 years after baseline examination, significant training effects were observed in the group exposed to the combined cognitive and physical training. The physical and cognitive status in the participants of this group could be preserved on a higher level compared to baseline, and the participants displayed fewer depressive symptoms than the no-treatment-control group. The results are discussed in the light of recent research regarding the effects of mental and physical activity on brain function in older adults.

Psychological and physical activity training for older persons: who does not attend?

BACKGROUND

Interventions to promote successful aging include psychological and physical activity programs. Identification of determinants of attendance of older persons may be useful to develop strategies to improve attendance. For physical activity programs determinants of attendance have been investigated extensively. For psychological programs hardly any knowledge is available. Determinants of attendance at psychological and physical activity programs have never been investigated simultaneously.

OBJECTIVE

To identify demographic, physical and psychological determinants of attendance of older subjects following multifaceted psychological training - aimed at promoting active social participation - and physical activity training and to compare the variation of these determinants between the two training programs.

METHOD

118 subjects aged 65-92 years were randomized over psychological and physical activity training. Determinants of attendance were obtained at pretest with questionnaires and performance-based tests.

RESULTS

Mean attendance was 62%. Attendance was not related to type of program. Having chronic diseases facilitated attendance in the psychological training group and limited attendance in the physical activity training group. Low and high levels of Activities of Daily Living performance (ADLs) and walking endurance were related to a high attendance in the psychological training group. A low level of activities of daily living (ADL) and a low walking endurance were related to a low attendance in the physical activity training group. For both training groups, persons living with a partner had higher attendance rates than persons living alone, and persons with a low level of anxiety had higher attendance rates than persons with a moderate or a high level of anxiety.

CONCLUSION

Psychological training may be more suitable for frail older persons with chronic diseases, low ADL levels and low walking endurance than physical activity training, and may help to prepare such persons for physical activity.

Effekte eines multimodalen Aktivierungsprogrammes (SimA-P) für Bewohner von Einrichtungen der stationären Altenhilfe

Lässt sich die verbliebene Selbstständigkeit von Pflegeheimbewohnern in kognitiver und funktioneller Hinsicht erhalten und fördern? Über die Möglichkeiten und Grenzen des Selbstständigkeitserhaltes durch geeignete therapeutische Methoden bei bereits pflegebedürftigen Bewohnern von Einrichtungen der stationären Altenhilfe ist wenig bekannt. Deshalb wurde im Rahmen des Forschungsprojektes “Rehabilitation im Altenpflegeheim” die Anwendbarkeit und Effektivität eines rehabilitativen Interventionsansatzes bei einer Pflegeheimklientel untersucht. Hierzu wurden an einer Stichprobe von 294 Bewohnern von Pflegeheimen im Alter von 70-99 Jahren psychologische, funktionelle und medizinische Variablen als Faktoren der Selbstständigkeit vor allem in den Bereichen der Aktivitäten des täglichen Lebens über einen Interventionszeitraum von 12 Monaten zu drei Zeitpunkten untersucht. Der Interventionsansatz geht aus den theoretischen und praktischen Ergebnissen der SimA-Studie (SimA = Selbstständig im Alter) (Oswald et al., seit 1991) hervor und berücksichtigt die Erkenntnisse aktueller geriatrischer und gerontopsychiatrischer Therapie- und Rehabilitationsstudien. Grundlage der Intervention stellt gemäß der Erkenntnisse der SimA-Studie eine Kombination aus kognitiver und körperlicher Aktivierung dar. Zusätzlich wurde für demenziell stärker eingeschränkte Pflegeheimbewohner ein spezifisch biographisch ausgerichtetes Aktivierungskonzept erarbeitet. Die Untersuchungsergebnisse zeigen signifikante Therapieeffekte auf kognitive und funktionelle Parameter sowie einen Transfer der Therapieinhalte auf Aktivitäten des täglichen Lebens und die Sturzhäufigkeit der Teilnehmer.

Factors explaining disability-free life expectancy in Japan: the proportion of older workers, self-reported health status, and the number of public health nurses

BACKGROUND

Disability-free life expectancy (DFLE) data for 47 prefectures in Japan were reported in 1999; however, few studies have identified the factors associated with the length of the DFLE. The objective of this study was to elucidate the primary factors that explain differences in DFLEs in Japan.

METHODS

In our ecological study, 47 prefectures in Japan were used as units of analysis. The DFLEs for men and women at 65 years of age (DFLE65), calculated by Hashimoto et al using Sullivan's method, were set as dependent variables. From various national surveys, 181 factors associated with demographics, socioeconomic status, health status and health behaviors, medical environment, social relationships, climate, and other areas were gathered as independent variables. Pearson's or Spearman's correlation coefficients were calculated to screen independent variables potentially associated with the DFLE65s. Then, multivariate linear regression analyses were conducted for the selected 24 independent variables after adjusting for the proportion of older people (65 years or more) and population density.

RESULTS

Multivariate linear regression analyses revealed that the large number of public health nurses per 100,000 population, a good self-reported health status, and a high proportion of older workers were significantly associated with long DFLE65s for both genders.

CONCLUSIONS

These three factors could potentially explain the differences in DFLE of the older population in Japan.

Differences between participants and non-participants in an RCT on physical activity and psychological interventions for older persons

BACKGROUND AND AIMS

Volunteer bias in intervention studies on successful aging has been poorly explored. This paper investigated differences between participants and non-participants of the Groningen Intervention Study on Successful Aging (GISSA) over a wide range of demographic, physical, psychological and social subject characteristics.

METHODS

Subjects were recruited among a longitudinal cohort study (Groningen Longitudinal Aging Study) and included 558 men and 711 women, aged 65-96 years, who were invited to participate in the GISSA. Measures were obtained by questionnaires at the moment of invitation and eight years before invitation. Participants were compared with three groups of non-participants: persons who refused to participate, those who did not respond after a reminder, and those who intended to participate but withdrew before pre-test.

RESULTS

At the moment of invitation, participants were younger, better educated, and functionally and physically more active than the three groups of non-participants. They also had better scores on the physical functioning subscale of the medical outcome scale, better ADL, iADL and vigorous ADL functions and fewer depressive symptoms, and perceived less social support in everyday and problem situations. Participants reported a less strong rate of decline in physical and psychological functioning in the eight years prior to the invitation than did the other groups.

CONCLUSION

Due to volunteer bias, results of intervention studies on successful aging may have limited generalizability.

Applying the transtheoretical model to the exercise behaviors of stroke patients

Individuals with disabilities, including stroke, are frequently deconditioned. A variety of factors, including infrequent exercise participation, may be responsible for the deconditioning observed. According to the transtheoretical model (TTM), individuals progress through cognitive processes, termed stages, that indicate their readiness to undertake a particular healthy behavior, such as exercise. Our study examined 178 community-dwelling stroke patients' readiness to initiate an exercise program and their current exercise patterns. Using the Stages of Change Questionnaire, we found over 75% of respondents to be in the exercise preadoption stages of precontemplation, contemplation, or preparation. Moreover, participants classified in the postadoption stages of maintenance and action reported exercising significantly more than those in the preadoption stages. Individuals in the postadoption stages were also participating in significantly more sessions of strenuous or moderate exercise than those in the preadoption stages. It was concluded that the TTM is a valid theoretical framework to measure stroke patients' readiness to participate in exercise. However, additional research examining the psychosocial and functional factors mitigating these attitudes, and the stability of these attitudes, needs to be performed.

Screening, safety, and adverse events in physical activity interventions: Collaborative experiences from the behavior change consortium

Researchers who conduct physical activity (PA) intervention studies provide an invaluable opportunity to further the prevention science knowledge base for implementing and delivering PA programs. Despite recommendations that screening is important to increase patient safety, the specific screening criteria best suited for different community applications are unknown. To add to the limited knowledge base, we examined the screening procedures and the occurrence of adverse events among more than 5,500 participants from 11 diverse PA interventions participating in a trans-National Institutes of Health (NIH) collaborative known as the Behavior Change Consortium (BCC). Numerous adverse events occur in sedentary, chronically ill, or older populations, although few are attributed to activity/exercise interventions. No serious study-related adverse events (SRAEs) were reported across different screening practices, interventions, and/or populations. Relatively few minor SRAEs were reported (primarily musculoskeletal injuries), emphasizing the need to be aware of potential musculoskeletal sequelae during exercise interventions. One common characteristic of these studies is that they recommended "start low and go slow" strategies, with moderate intensity PA as the goal behavior. Recommendations to reframe the meaning and use of screening criteria to initiate PA in the community are discussed. Although we were unable to conduct generalizable quantitative analyses from our data, the combined experience of the BCC studies provides a unique opportunity to examine PA-related screening and safety issues across diverse populations, settings, and intervention programs.

Does urinary incontinence affect middle-aged and older women's time use and activity patterns?

OBJECTIVE

To investigate the relationship between urinary incontinence and women's levels and hours of participation in 31 activities.

METHODS

A subset of panel members from the Health and Retirement Study completed the self-administered Consumption and Activities Mail Survey questionnaire in 2001. These data were linked with Health and Retirement Study 2000 data. Analyses were limited to 2,190 female Consumption and Activities Mail Survey self-respondents born in 1947 or earlier. Logistic regression was used to predict activity participation. Linear regression was used to predict the number of hours of participation.

RESULTS

The hypothesis that urinary incontinence affects women's time use and activity patterns was supported. Compared with the continent women, the incontinent women were less likely to have house cleaned, shopped, physically shown affection, or attended religious services in the recent past; and were more likely to have watched television or made music by singing or playing an instrument. Compared with continent activity participants, incontinent participants reported significantly fewer hours spent walking, communicating with friends and family by telephone or e-mail, working for pay, using a computer, and engaging in personal grooming and hygiene.

CONCLUSION

These findings substantiate prior work on the relationship between urinary incontinence and quality of life, and suggest a useful route for educating patients about the impact of urinary incontinence. Clinicians must be alert to opportunities for encouraging incontinent women to be active. It is also important to consider the implications for time use and activity patterns when advising patients about treatment and management options.

LEVEL OF EVIDENCE

II-2.

Test-retest reliability of Yale Physical Activity Survey among older Mexican American adults: a pilot investigation

The objective of the work reported in this paper is to assess test-retest reliability of Yale Physical Activity Survey Total Time, Estimated Energy Expenditure, Activity Dimension Indices, and Activities Check-list in older Mexican American men and women. A convenience-based healthy sample of 49 (42 women and 7 men) older Mexican American adults recruited from senior recreation centers aged 68 to 80 years volunteered to participate in this pilot study. Forty-nine older Mexican American adults filled out the Yale Physical Activity Survey for this study. Fifteen (12 women and 3 men) of the 49 volunteers responded twice to the Yale Physical Activity Survey after a 2-week period, and helped assess the test-retest reliability of the Yale Physical Activity Survey. Results indicate that based on a 2-week test-retest administration, the Yale Physical Activity Survey was found to have moderate (rhoI= .424, p < .05) to good reliability (rs = .789, p < .01) for physical activity assessment in older Mexican American adults who responded.

Factors influencing the exercise behavior of adults with physical disabilities

PURPOSE

Examine the theorized associations of transtheoretical model (TTM) of behavior change constructs (behavioral and cognitive processes of change, decisional balance, and self-efficacy), along with exercise barriers, by stage of change for exercise behavior among individuals with physical disabilities.

METHODS

Cross-sectional survey of 322 adults with physical disabilities residing in the United States. Most participants (84.3%) used some form of assistive device (e.g., artificial limb, wheelchair), were female (62.1%), and Caucasian (91.9%). The mean age of participants was 52.5 yr (SD = 13.9). Participants completed and returned questionnaires for each TTM construct, along with an exercise barriers measure.

RESULTS

In univariate analyses, all constructs were significantly (P < 0.001) associated with the stages of change for exercise behavior, except for dramatic relief (P > 0.005). The largest portion of variance was derived from counter conditioning (eta = 0.45), followed by the five behavioral processes of change combined (eta = 0.40), self-liberation (eta = 0.31), self-efficacy (eta = 0.30), and self-reevaluation (eta = 0.28). Direct discriminant function (multivariate) analysis revealed four discriminant functions which accounted for 71.0% (P < 0.001), 20.9% (P < 0.001), 6.3% (P < 0.05), and 1.8% (P = 0.62), respectively, of the between-group (stage of change) variability. The overall stage of change classification accuracy was 70.8%.

CONCLUSION

This was the first study to examine the stages of change for exercise behavior among adults with physical disabilities on the basis of the full TTM and exercise barriers. Overall, the results are in general agreement with existing evidence among nondisabled populations. This provides further cross-sectional support for the internal and external validity of TTM and exercise barriers among a unique and understudied population segment.

The Israeli kibbutz as a venue for reduced disability in old age: lessons from the Cross-sectional And Longitudinal Aging Study (CALAS)

It is important to identify ways to moderate disability in old age. We assessed whether the kibbutz way of life results in reduced disability by examining risk factors for disability in three comparable populations: kibbutz members (lifetime kibbutz exposure); parents of kibbutz members who came to live on the kibbutz in old age due to health and social needs (old age exposure); and comparable Israelis in the general population (no exposure). Kibbutz members were less disabled, defined as needing help with at least one of five activities of daily living, than the other groups. Kibbutz members had 30% lower risk of disability, after controlling for sociodemographics and social networks, health and health behaviors, and life history and background. Introducing length of residence in current home and death of a child to the analysis reduced this finding to non-significance. Overall, risk of disability was significantly higher for older age groups, women, homemakers, people with more comorbid conditions, those with more children, and those with a child that had died, while risk of disability was significantly lower for those with larger social networks, those who had engaged in physical activity at midlife, and those who had lived in their homes longer. Since occupations on the kibbutz (primarily agricultural and blue collar) have equal pay, and kibbutz members have complete economic security, our results suggest that it is not such occupations themselves but their association with low incomes that have contributed to previous associations of blue collar and agricultural occupations with poor health and high disability. Lower disability among kibbutz members may be due to the social, economic, and instrumental support provided on the kibbutz, as well as to an active life style, suggesting features of kibbutz life that can be replicated elsewhere to reduce disability.

Promoting exercise behavior in older adults: using a cognitive behavioral intervention

Health benefits associated with exercise are only obtained when exercise is maintained. The purpose of this pilot study was to examine the effects of a cognitive behavioral therapy (CBT) intervention on exercise behavior and physical outcomes in older adults. All participants were taught progressive flexibility, strength, and endurance exercises. The control group received no additional treatment. The experimental group was taught to recognize negative thoughts related to exercise and to counter these thoughts with more positive ones. Subsequent exercise behavior and physical outcomes were measured in all participants. Cognitive behavioral therapy was moderately to largely effective in improving the majority of physical outcomes assessed. In addition, CBT was moderately effective in improving several components of self-reported exercise behavior and mildly effective in improving exercise behavior overall. Results suggest that nurses can train older adults to identify and modify thoughts that interfere with or reduce their exercise behavior and thus improve physical functioning.

Exercise and aging

There is increasing evidence that the black box we have referred to as"biologic aging" is composed of genetic factors and many types of environmental exposures. Some of the most potentially modifiable elements of this syndrome are those attributable to disuse or insufficient exposure to certain kinds or intensities of physical stressors during the course of the life span. Beneficial adaptations to exercise once thought restricted to genetically endowed master athletes now are seen to occur just as predictably in frail elders with chronic disease, opening the door to vastly improved physical function and associated health benefits. Knowledge of the benefits of physical activity, however well substantiated, may be necessary, but it is not sufficient to change either physician-prescribing habits or the likelihood of adoption and long-term adherence to exercise on the part of patients. Ultimately, the penetration of an exercise prescription to optimize aging into the most inactive cohorts in the community,who have the most to gain from increases in levels of physical activity and fitness, will depend on a combination of clear evidence-based guidelines coupled with health professional training and behavioral programs tailored to age-specific barriers and motivational factors.

Exercise Training Program for Older Adults Incentives and Disincentives for Participation

The purpose of this study was to describe the incentives and disincentives for participating in an exercise training program for community-dwelling individuals 78 and older. One hundred forty-seven women and 62 men participated in this descriptive study, and ages ranged from 78 to 95 years (mean 82.7 +/- 4.1). Individuals were interviewed by phone about their decision to participate in an exercise program. Qualitative responses were analyzed using content analysis. Three main incentive themes emerged: Health Benefits, Psychological Benefits, and Positive Program Features. Disincentive themes included Competing Commitments, Doubts about Exercise, and Negative Program Features. To better tailor an exercise program to the needs of this older age group, nurses working with older adults should keep in mind the lifestyle, age-specific obligations, and set of values affecting this cohort's participation.

Community-based senior health promotion program using a collaborative practice model: the Escalante Health Partnerships

Recent research demonstrates that, although the risk of disease and disability clearly increases with age, poor health need not be an inevitable consequence of aging. A healthy lifestyle is more influential than genetic factors in assisting older adults avoid the decline and deterioration traditionally associated with aging. Many effective strategies for reducing disease and disability are widely underused. The Escalante Health Partnerships is a community-based, nurse-managed health promotion and chronic disease care management program for community-residing older adults. The program base supports a multidisciplinary, collaborative practice model, which has responded to the health needs of members of a community at high risk of having or developing chronic conditions. Preliminary comparisons of the health status of program participants with national norms demonstrate that these seniors report better general health, performance of roles, and social functioning, with the strongest correlations occurring between general health and vitality and between general health and role-physical. In addition, these participants have 4.2 doctor visits per year, in comparison with 7.1 office visits for a national comparison group and 1.6 hospital days per year, in comparison with 2.1 hospital days in the same referenced population. This collaborative partnership is a model that can be replicated cost-effectively in other communities.

Urban residential environments and senior citizens' longevity in megacity areas: the importance of walkable green spaces

STUDY OBJECTIVES

To study the association between greenery filled public areas that are nearby a residence and easy to walk in and the longevity of senior citizens in a densely populated, developed megacity.

DESIGN

Cohort study.

METHODS

The authors analysed the five year survival of 3144 people born in 1903, 1908, 1913, or 1918 who consented to a follow up survey from the records of registered Tokyo citizens in relation to baseline residential environment characteristics in 1992.

MAIN RESULTS

The survival of 2211 and the death of 897 (98.9% follow up) were confirmed. The probability of five year survival of the senior citizens studied increased in accordance with the space for taking a stroll near the residence (p<0.01), parks and tree lined streets near the residence (p<0.05), and their preference to continue to live in their current community (p<0.01). The principal component analysis from the baseline residential environment characteristics identified two environment related factors: the factor of walkable green streets and spaces near the residence and the factor of a positive attitude to a person's own community. After controlling the effects of the residents' age, sex, marital status, and socioeconomic status, the factor of walkable green streets and spaces near the residence showed significant predictive value for the survival of the urban senior citizens over the following five years (p<0.01).

CONCLUSIONS

Living in areas with walkable green spaces positively influenced the longevity of urban senior citizens independent of their age, sex, marital status, baseline functional status, and socioeconomic status. Greenery filled public areas that are nearby and easy to walk in should be further emphasised in urban planning for the development and re-development of densely populated areas in a megacity. Close collaboration should be undertaken among the health, construction, civil engineering, planning, and other concerned sectors in the context of the healthy urban policy, so as to promote the health of senior citizens.

Urban residential environments and senior citizens' longevity in megacity areas: the importance of walkable green spaces

STUDY OBJECTIVES

To study the association between greenery filled public areas that are nearby a residence and easy to walk in and the longevity of senior citizens in a densely populated, developed megacity.

DESIGN

Cohort study.

METHODS

The authors analysed the five year survival of 3144 people born in 1903, 1908, 1913, or 1918 who consented to a follow up survey from the records of registered Tokyo citizens in relation to baseline residential environment characteristics in 1992.

MAIN RESULTS

The survival of 2211 and the death of 897 (98.9% follow up) were confirmed. The probability of five year survival of the senior citizens studied increased in accordance with the space for taking a stroll near the residence (p<0.01), parks and tree lined streets near the residence (p<0.05), and their preference to continue to live in their current community (p<0.01). The principal component analysis from the baseline residential environment characteristics identified two environment related factors: the factor of walkable green streets and spaces near the residence and the factor of a positive attitude to a person's own community. After controlling the effects of the residents' age, sex, marital status, and socioeconomic status, the factor of walkable green streets and spaces near the residence showed significant predictive value for the survival of the urban senior citizens over the following five years (p<0.01).

CONCLUSIONS

Living in areas with walkable green spaces positively influenced the longevity of urban senior citizens independent of their age, sex, marital status, baseline functional status, and socioeconomic status. Greenery filled public areas that are nearby and easy to walk in should be further emphasised in urban planning for the development and re-development of densely populated areas in a megacity. Close collaboration should be undertaken among the health, construction, civil engineering, planning, and other concerned sectors in the context of the healthy urban policy, so as to promote the health of senior citizens.

Exercise to prevent and treat functional disability

There are myriad ways in which optimal levels of physical activity over the course of the life span could potentially contribute to the prevention of functional disability in old age. These include direct effects of exercise to maximize physiologic capacity and prevent or delay the onset of disability-related conditions and more indirect effects, such as the modulation of psychosocial factors important in the expression of disability. Epidemiologic studies strongly suggest that functional disability is inversely related to physical activity level or physical fitness in various domains. Experimental studies confirm the benefits of exercise on correlates of disability, such as impairments of muscle strength or performance-based tests of functional limitations. However, the evidence that exercise can actually prevent disability in the long-term is not yet established by data from randomized clinical trials in the general population. Secondary prevention of disability in frail elders has been shown in a few trials. The available evidence, however, suggests that a rational exercise prescription for the prevention and treatment of disability at this time should include promotion of a physically active lifestyle and specific exercises targeting aerobic capacity, strength, and balance. Differential emphasis on specific elements of this prescription may be necessary and appropriate, depending on the etiology of the disability in specific cohorts, severity of physical impairments and functional limitations, and other individual characteristics relevant to exercise feasibility, safety, and efficacy.

Long-term impact of preventive proactivity on quality of life of the old-old

OBJECTIVE

This research explored the long-term benefits of engaging in proactive health promotion efforts among old-old residents of Sunbelt retirement communities to empirically test components of the Preventive and Corrective Proactivity (PCP) Model of Successful Aging. Specifically, we examined the contributions of exercise, tobacco use, moderate alcohol use, and annual medical checkups to multidimensional quality of life indicators of physical health, psychological well-being, and mortality.

METHOD

Data were obtained from a longitudinal study of adaptation to aging. Annual in-home interviews were conducted with 1000 older adults over a 9-year period. Whether health promotion behaviors at baseline predicted quality of life outcomes 8 years later was examined, controlling for the baseline outcome, sociodemographic variables, and, as an additional test, baseline health conditions.

RESULTS

Exercise was predictive of fewer IADL limitations and greater longevity, positive affect, and meaning in life 8 years later. Avoiding tobacco was predictive of longevity. Before controlling for health conditions, exercise predicted decreased risk of basic activities of daily living limitations and having more goals; moderate alcohol use predicted longevity; annual health checkup predicted more IADL limitations; and having once smoked predicted having more IADL limitations and negative affect.

CONCLUSIONS

Among the old-old, exercise had long-term and multifaceted benefits over an 8-year period. Tobacco avoidance also contributed to long-term positive outcomes. These results lend support to the long-term preventive value of health-promoting proactivity spontaneously engaged in by old-old persons proposed in the framework of the PCP model.

Demographic and psychosocial correlates of physical activity in late life

INTRODUCTION

According to the Centers for Disease Control and Prevention and the World Health Organization, increasing physical activity may help prolong health and preserve the quality of life in late adulthood. Physical activity has taken center stage as the behavior most likely to alter health. However, there is little recent population-wide information about the demographic and psychosocial correlates of physical activity in the elderly population. The purpose of the study was to identify the factors associated with older adults' frequency of physical activity. The study may have implications for preventive interventions.

METHODS

Data for 12,611 community-dwelling people aged > or = 65 from the 1996-1997 Canadian National Population Health Survey were examined. Predictors of frequent versus infrequent self-reported physical activity lasting > 15 minutes were examined using logistic regression analyses. The predictor variables included geographic location, psychological distress (Generalized Distress Scale), demographic factors (age, gender, educational level, and marital status), perceived social support, chronic medical conditions, physical limitations due to injury, functional limitations, smoking behavior, and body mass index (BMI).

RESULTS

Gender (male); younger age; higher levels of education; being unmarried; absence of chronic conditions, injuries, and functional limitations; lower BMI; social support (females); nonsmoking; region; and lower levels of psychological distress were associated with frequent physical activity in late life. Older adults in western Canadian provinces were more active than those in eastern provinces.

CONCLUSIONS

The results will be useful for the design of interventions aimed at improving older adults' health behavior and other health and functional outcomes, especially for subgroups in particular need. Recommendations for further longitudinal research are presented.

Have we oversold the benefit of late-life exercise?

BACKGROUND

Increasing exercise among older adults to improve function and prevent or decrease disability is widely promoted in developed countries. This review seeks to critically evaluate the degree to which existing scientific evidence supports these claims.

METHODS

A literature review was performed in Medline and Best Evidence databases for the years 1985 to 2000. Experimental and quasi-experimental aerobic and resistance exercise interventions were reviewed for impairment, function, and disability outcomes. The impact of exercise on specific impairments, functions, and disabilities was examined by summarizing the findings reported across all studies.

RESULTS

Thirty-one studies were identified. Impairment and functional outcomes were reported in 97% and 81% of the studies, respectively; half of the studies examined disability outcomes. The most consistent positive effects of late-life exercise were observed in strength, aerobic capacity, flexibility, walking, and standing balance, with over half of the studies that examined these outcomes finding positive effects. Of the studies that examined physical, social, emotional, or overall disability outcomes, most found no improvements. In the five studies that reported reduced physical disability, the effect sizes ranged from .23 to .88.

CONCLUSIONS

Late-life exercise clearly improves strength, aerobic capacity, flexibility, and physical function. Existing scientific evidence, however, does not support a strong argument for late-life exercise as an effective means of reducing disability. This may be due, in part, to methodological limitations in studies that have examined disability outcomes. On the other hand, the theoretical basis of interventions aimed at reducing disability may need to extend beyond exercise and address behavioral and social factors.

Health promotion for older Americans in the 21st century

OBJECTIVES

To provide a broad overview of the role of the individual, the physical environment, and the social environment on health and functioning in older adults (65 and older), and to highlight interventions and recommendations for action on each of these levels.

DATA SOURCES

Published studies and government reports on health and functioning in older Americans and on the individual, social, and physical environmental contributors to health were identified through journal and government documents review and computer library searches of medical and social science data bases for 1980-1999.

STUDY SELECTION

Preference was given to published studies and government reports that focused specifically on behavioral and environmental contributors and barriers to health promotion in Americans 65 and older and/or that highlighted creative interventions with relevance to this population. Both review articles and presentations of original research were included, with the latter selected based on soundness of design and execution and/or creativity of intervention described.

DATA EXTRACTION

Studies were examined and their findings organized under three major headings: (1) behavioral risk factors and risk reduction, including current government standards for prevention and screening; (2) the role of the physical environment; and (3) the role of the social environment in relation to health promotion of older adults.

DATA SYNTHESIS

Although most attention has been paid to the role of behavioral factors in health promotion for older adults, a substantial body of evidence suggests that physical and social environmental factors also play a key role. Similarly, interventions that promote individual behavioral risk reduction and interventions targeting the broader social or physical environment all may contribute to health in the later years.

CONCLUSIONS

With the rapid aging of America's population, increased attention must be focused on health promotion for those who are or will soon be older adults. Promising intervention strategies addressing the individual, the physical environment, and the social environment should be identified and tested, and their potential for replication explored, as we work toward a more comprehensive approach to improving the health of older Americans in the 21st century.

Waging war on modern chronic diseases: primary prevention through exercise biology

In this review, we develop a blueprint for exercise biology research in the new millennium. The first part of our plan provides statistics to support the contention that there has been an epidemic emergence of modern chronic diseases in the latter part of the 20th century. The health care costs of these conditions were almost two-thirds of a trillion dollars and affected 90 million Americans in 1990. We estimate that these costs are now approaching $1 trillion and stand to further dramatically increase as the baby boom generation ages. We discuss the reaction of the biomedical establishment to this epidemic, which has primarily been to apply modern technologies to stabilize overt clinical problems (e.g., secondary and tertiary prevention). Because this approach has been largely unsuccessful in reversing the epidemic, we argue that more emphasis must be placed on novel approaches such as primary prevention, which requires attacking the environmental roots of these conditions. In this respect, a strong association exists between the increase in physical inactivity and the emergence of modern chronic diseases in 20th century industrialized societies. Approximately 250,000 deaths per year in the United States are premature due to physical inactivity. Epidemiological data have established that physical inactivity increases the incidence of at least 17 unhealthy conditions, almost all of which are chronic diseases or considered risk factors for chronic diseases. Therefore, as part of this review, we present the concept that the human genome evolved within an environment of high physical activity. Accordingly, we propose that exercise biologists do not study "the effect of physical activity" but in reality study the effect of reintroducing exercise into an unhealthy sedentary population that is genetically programmed to expect physical activity. On the basis of healthy gene function, exercise research should thus be viewed from a nontraditional perspective in that the "control" group should actually be taken from a physically active population and not from a sedentary population with its predisposition to modern chronic diseases. We provide exciting examples of exercise biology research that is elucidating the underlying mechanisms by which physical inactivity may predispose individuals to chronic disease conditions, such as mechanisms contributing to insulin resistance and decreased skeletal muscle lipoprotein lipase activity. Some findings have been surprising and remarkable in that novel signaling mechanisms have been discovered that vary with the type and level of physical activity/inactivity at multiple levels of gene expression. Because this area of research is underfunded despite its high impact, the final part of our blueprint for the next millennium calls for the National Institutes of Health (NIH) to establish a major initiative devoted to the study of the biology of the primary prevention of modern chronic diseases. We justify this in several ways, including the following estimate: if the percentage of all US morbidity and mortality statistics attributed to the combination of physical inactivity and inappropriate diet were applied as a percentage of the NIH's total operating budget, the resulting funds would equal the budgets of two full institutes at the NIH! Furthermore, the fiscal support of studies elucidating the scientific foundation(s) targeted by primary prevention strategies in other public health efforts has resulted in an increased efficacy of the overall prevention effort. We estimate that physical inactivity impacts 80-90% of the 24 integrated review group (IRG) topics proposed by the NIH's Panel on Scientific Boundaries for Review, which is currently directing a major restructuring of the NIH's scientific funding system. Unfortunately, the primary prevention of chronic disease and the investigation of physical activity/inactivity and/or exercise are not mentioned in the almost 200 total subtopics comprising t

Disability in older adults. 3: Policy implications

Several models of disability proposed in recent years share many common elements and are helping to direct research and inform practice. One new development is that disablement, a concept that emphasizes the impairments--handicap continuum, is now being implemented by concepts related to enablement. Enablement focuses attention on the capacity for rehabilitation. Coincidentally, a new generation of functional assessment measures has evolved that allow greater sensitivity not only to levels of disability but also to levels of ability. Together, the new models and tools hold promise of providing a more sensitive evaluation of rehabilitation efforts and a more accurate forecasting of future needs.