Mobility, balance and frailty in community-dwelling older adults: What is the best 1-year predictor of falls?

Effect of lower-extremity muscle power training on muscle strength, balance function and walking ability in older adults with heart failure: a randomized controlled trial

PURPOSE

This study investigated the combined effect of lower-extremity muscle power training and regular cardiac rehabilitation on muscle strength, balance function, and walking ability of older adults with heart failure.

METHODS

Thirty-one patients, comprising 17 males and 14 females, aged between 66 and 89 years and diagnosed with non-severe heart failure, were randomly assigned to either the intervention group (n = 15) or control group (n = 16). Both groups participated in a 12-week regular rehabilitation program, with the intervention group receiving additional lower-extremity muscle power training. Various outcome measures, including muscle strength (the five-times-sit-to-stand test and knee extensor peak torque), balance function (Berg balance scale and functional reach test), and walking ability (4-m walk and Timed Up-and-Go tests) were assessed at baseline and 12 weeks after the intervention.

RESULTS

Of the 31 participants, 27 completed the study protocol. The intervention group demonstrated significantly greater improvement in the five-times-sit-to-stand test time, indicating enhanced lower-extremity muscle power compared to the control group. Both groups showed significant differences in the Berg balance scale, functional reach test, 4-m walk test, and Timed Up-and-Go test between baseline and 12 weeks. However, the effect sizes for the changes during the study period were larger in the intervention group (d = 0.74-1.19) than the control group (d = 0.57-0.96).

CONCLUSION

Combining lower-extremity muscle power training with regular cardiac rehabilitation may lead to additional improvements in muscle function for older adults with heart failure, resulting in enhanced dynamic balance and walking ability.

TRIAL REGISTRATION NUMBER/DATE OF REGISTRATION

UMIN000032087/April 4, 2018.

Correlates of frailty in older female cancer survivors

INTRODUCTION

Cancer survivors are at risk of frailty because of cancer and its treatment. Understanding the factors that increase the risk of frailty is an important aspect of cancer care for the development of interventions to prevent or manage frailty, thus improving cancer survival and overall quality of life of cancer survivors. This study aimed to identify demographic, clinical, and psychosocial correlates of frailty in older, female cancer survivors.

MATERIALS AND METHODS

This is a sub-study focusing on the exploratory aim of a larger cross-sectional study (NURS-IIR-IUSCC-0748). A total of 213 female cancer survivors aged 59-87 years old were included from the parent study in the current analysis. Frailty, the primary outcome, was measured using the Tilburg Frailty Indicator scale. The independent variables were age, relationship status, clinical stage of cancer, treatment type, comorbidity, depression, affect, optimism, stress, and social support. Stepwise linear regression modeling identified the independent variables that were significantly associated with frailty.

RESULTS

The final regression model revealed that high patient-reported stress and depression, comorbidity, not being married or living with a partner, and low positive affect were significantly associated with worsening frailty in this population.

DISCUSSION

Understanding the context of frailty is important for the design of interventions that target factors known to be associated with frailty in older cancer survivors. Further validation with a larger and a more diverse sample from a broad spectrum of sociodemographic and clinical population would fully account for the multiple independent variables influencing frailty in cancer survivors.

Association between Prevention from Going Out and Incidence of Falls among Community-Dwelling Older Adults during COVID-19 Pandemic

To prevent falls, community-dwelling older adults must maintain regular physical activities. This study aimed to explore the association between the prevention from going out and the incidence of falls among community-dwelling older adults during the COVID-19 pandemic. We conducted a prospective cohort study that consisted of 381 individuals aged 65 years or older, living in a local community in Japan, and ranging from being independent to being physically and cognitively frail. The finding revealed that among those who had been going out five or more times weekly pre-pandemic, the prevention from going out at the time of the first state of emergency (SOE) (AOR = 6.84; 95%CI = 1.51-31.02), having history of falls (AOR = 7.35; 95%CI = 1.81-29.84), participating in group gatherings (AOR = 6.09; 95%CI = 1.48-25.12), living with spouses (AOR = 0.08; 95%CI = 0.02-0.40), and living with other than spouse (AOR = 0.15; 95%CI = 0.03-0.73) were associated with the incidence of falls. The study highlights the importance of providing regular opportunities to go out to community-dwelling older adults in order to prevent falls.

Effects of a Multicomponent Exercise Program on Prevalence and Severity of the Frailty Syndrome in a Sample of Italian Community-Dwelling Older Adults

Background: Frailty is a well-known condition that leads to a lack of resilience, with a reduced homeostatic capacity and a consequent higher risk of suffering adverse health outcomes. This study investigated the effectiveness of an exercise program to improve and reverse physical frailty amongst Italian older adults. Methods: One hundred and twenty-three community dwelling older adults (mean age 74 years, SD = 6; 64% women) were involved in an experimental (EG; n = 62) and a control (CG; n = 61) group. Frailty was assessed at baseline and after the intervention using an adapted version of the frailty phenotype. The EG took part in a 16-week exercise program, consisting of endurance, strength, balance and flexibility exercises, while the CG maintained the same routine. Results: After the exercise program, the EG was more robust than the CG (F = 43.51, p < 0.001). Within the EG, 46% of pre-frail and 50% of frail people reached the robust and pre-frail levels, respectively. Effects of training were higher in frail and pre-frail people (reduction of frailty of 0.67 and 0.76 points, respectively) compared to robust ones (who frailty levels increased by 0.23 points; F = 11.32, p < 0.001). Conclusions: A multicomponent exercise program may be effective at improving and reverting frailty, specifically for frail and pre-frail people.

The Tilburg Frailty Indicator: A psychometric systematic review

BACKGROUND

The Tilburg Frailty Indicator (TFI) is one of the most prominent multidimensional frailty assessment instruments. This review aimed to critically appraise and summarise its measurement properties.

METHODS

Reports were eligible if they included results of studies aimed at developing the TFI or evaluating its measurement properties. We performed a literature search in MEDLINE, CINAHL, and PsycINFO databases from their inception until December 8, 2021. We also searched grey literature databases. We assessed the methodological quality of the included studies using the "COSMIN Risk of Bias". The measurement properties were evaluated using specific criteria. We graded the quality of the evidence using a GRADE approach.

RESULTS

Sixty-three studies were included. We found moderate sufficient evidence for TFI content validity, although it is still insufficient for the comprehensiveness of its items. TFI construct validity was based on sufficient evidence from two studies of its structural validity as well as multiple hypothesis-testing for construct validity studies with inconsistent results. We did not find any studies that assessed cross-cultural validity. Only one of TFI's three dimensions showed sufficient evidence for the internal consistency of its scores, and results in test-retest reliability were inconsistent. The TFI showed high sufficient concurrent validity with the comprehensive geriatric assessment. We identified several studies assessing its predictive validity for adverse frailty-related outcomes, although most of the evidence from these studies was insufficient. We did not find any studies that assessed the responsiveness of TFI scores.

CONCLUSIONS

The TFI had evidence gaps in several relevant measurement properties. Further research is needed to strengthen its usefulness as a clinical decision-making tool.

Predictive Validity of Motor Fitness and Flexibility Tests in Adults and Older Adults: A Systematic Review

Motor fitness and flexibility have been linked to several health issues. We aimed to investigate the predictive validity of motor fitness and flexibility tests in relation to health outcomes in adults and older adults. Web of Science and PubMed databases were screened for studies published from inception to November 2020. Two authors systematically searched, evaluated, and extracted data from identified original studies and systematic reviews/meta-analysis. Three levels of evidence were constructed: strong, moderate, and limited/inconclusive evidence. In total, 1182 studies were identified, and 70 studies and 6 systematic reviews/meta-analysis were summarized. Strong evidence indicated that (i) slower gait speed predicts falls and institutionalization/hospitalization in adults over 60 years old, cognitive decline/impairment over 55 years old, mobility disability over 50 years old, disability in instrumental activities of daily living (IADL) over 54 years old, cardiovascular disease risk over 45 years old, and all-cause mortality over 35 years old; (ii) impaired balance predicts falls and disability in IADL/mobility disability in adults over 40 years old and all-cause mortality over 53 years old; (iii) worse timed up&go test (TUG) predicts falls and fear of falling over 40 years old. Evidence supports that slower gait speed, impaired balance, and worse TUG performance are significantly associated with an increased risk of adverse health outcomes in adults.

A systematic review of one-legged balance performance and falls risk in community-dwelling adults

OBJECTIVE

The aim of this systematic review was to synthesise all published evidence on associations between one-legged balance performance and falls.

METHODS

Medline, EMBASE, CINAHL and Web of Science were systematically searched (to January 2021) to identify peer-reviewed, English language journal articles examining the association between one-legged balance performance and falls in community-dwelling adults.

RESULTS

Of 4310 records screened, 55 papers were included (n = 36954 participants). There was considerable heterogeneity between studies including differences in study characteristics, ascertainment of balance and falls, and analytical approaches. A meta-analysis of the time that individuals could maintain the one-legged balance position indicated that fallers had worse balance times than non-fallers (standardised mean difference: -0.29 (95%CI:-0.38,-0.20) in cross-sectional analyses; -0.19 (-0.28, -0.09) in longitudinal analyses), although there was no difference in the pooled median difference. Due to between-study heterogeneity, regression estimates between balance and fall outcomes could not be synthesised. Where assessed, prognostic accuracy indicators suggested that one-legged balance was a poor discriminator of fall risk; for example, 5 of 7 studies demonstrated poor prognostic accuracy (Area Under the Curve <0.6), with most studies demonstrating poor sensitivity.

CONCLUSIONS

This systematic review identified 55 papers that examined associations between balance and fall risk, the majority in older aged adults. However, the evidence was commonly of low quality and results were inconsistent. This contradicts previous perceptions of one-legged balance as a useful fall risk tool and highlights crucial gaps that must be addressed in order to translate such assessments to clinical settings.

Mobility impact and well-being in later life: A multidisciplinary systematic review

In modern societies, the understanding of how active mobility affects the elderly's psycho-physical well-being is crucial to design ageing-friendly transport measures. From a multidisciplinary perspective, this systematic review points out the mobility impact on three elements of the EU Active Ageing Index: health, independence and social connectedness. By scanning four databases (Scopus, Web of Science, PubMed, and TRID), 3727 peer-reviewed papers published in the last decade were found, of which 57 met the inclusion criteria. The screening process was conducted following the PRISMA protocol and registered to the database PROSPERO, while the quality assessment was done using the Mixed Methods Appraisal Tool. More than 80% of the papers showed that an active mobility prevents psycho-physical harms, while only few papers study the relation of mobility with independence and social inclusion, to reduce the need for assistance and the related public expenditures. The findings of this review give important information both to transportation researchers and policymakers and companies, underlining the need for further research as well as investments in targeted age-friendly transport systems. The Covid-19 emergency has further underlined the importance of this issue, being the elderly one of the more disadvantaged and frailer social group.

The balance function is associated with frailty in community-dwelling older women

Conditions underlying balance impairment should be identified to improve knowledge regarding clinical interventions for frail older adults. This study aims to explore the relationship between balance functions and frailty by using the brief balance evaluation systems test (BESTest), which can assess biomechanical constraints, stability limits/verticality, anticipatory postural adjustments (APAs), reactive postural responses, sensory orientation and stability in gait. A total of 75 community-dwelling older women were included in this cross-sectional study. We evaluated frailty by using the Kihon checklist and assessed the participants' balance functions by using the Brief BESTest. We performed the Mann-Whitney U test and receiver operating characteristic curve analysis to compare each balance function between frail and nonfrail participants. Twenty-two of the 75 (29.3%) participants were included in the frailty group. We noted significant differences between the frailty and nonfrailty groups with regard to stability limit, APAs, sensory orientation, and stability in gait (P = 0.010, 0.001, 0.008 and <0.001, respectively). In terms of determining frailty and nonfrailty, APAs and stability in gait were moderately accurate (the area under the curve = 0.730 and 0.713, respectively). APAs showed the highest sensitivity (0.864), whereas stability limits, sensory orientation, and stability in gait showed the highest specificity (0.943, 0.849 and 0.868, respectively). Thus, frail and nonfrail older adults showed significantly different balance functions, such as stability limits, APAs, sensory orientation and stability in gait. The Brief BESTest is useful for evaluating balance functions in relation to frailty.

Validation of a Laser Ranged Scanner-Based Detection of Spatio-Temporal Gait Parameters Using the aTUG Chair

This article covers the suitability to measure gait-parameters via a Laser Range Scanner (LRS) that was placed below a chair during the walking phase of the Timed Up&Go Test in a cohort of 92 older adults (mean age 73.5). The results of our study demonstrated a high concordance of gait measurements using a LRS in comparison to the reference GAITRite walkway. Most of aTUG's gait parameters demonstrate a strong correlation coefficient with the GAITRite, indicating high measurement accuracy for the spatial gait parameters. Measurements of velocity had a correlation coefficient of 99%, which can be interpreted as an excellent measurement accuracy. Cadence showed a slightly lower correlation coefficient of 96%, which is still an exceptionally good result, while step length demonstrated a correlation coefficient of 98% per leg and stride length with an accuracy of 99% per leg. In addition to confirming the technical validation of the aTUG regarding its ability to measure gait parameters, we compared results from the GAITRite and the aTUG for several parameters (cadence, velocity, and step length) with results from the Berg Balance Scale (BBS) and the Activities-Specific Balance Confidence-(ABC)-Scale assessments. With confidence coefficients for BBS and velocity, cadence and step length ranging from 0.595 to 0.798 and for ABC ranging from 0.395 to 0.541, both scales demonstrated only a medium-sized correlation. Thus, we found an association of better walking ability (represented by the measured gait parameters) with better balance (BBC) and balance confidence (ABC) overall scores via linear regression. This results from the fact that the BBS incorporates both static and dynamic balance measures and thus, only partly reflects functional requirements for walking. For the ABC score, this effect was even more pronounced. As this is to our best knowledge the first evaluation of the association between gait parameters and these balance scores, we will further investigate this phenomenon and aim to integrate further measures into the aTUG to achieve an increased sensitivity for balance ability.

Predicting Adverse Outcomes in Healthy Aging Community-Dwelling Early-Old Adults with the Timed Up and Go Test

Background

Simple, easy-to-perform, safe and cost-effective methods for the prediction of adverse outcomes in older adults are essential for the identification of patients who are most likely to benefit from early preventive interventions.

Methods

The study included 160 community-dwelling individuals aged 60-74 years, with 44.4% women. A comprehensive geriatric assessment was performed in all participants. Bioimpedance body composition analysis included 149 subjects. Among other tests, functional assessment included the Barthel Index of Activities of Daily Living (Barthel Index), Mini-Mental State Examination (MMSE), Timed Up and Go (TUG) and Fried frailty phenotype. Follow-up by telephone was made after at least 365 days. The composite endpoint (CE) included fall, hospitalization, institutionalization and death.

Results

Cohort characteristics: age 66.8±4.2 years (mean±SD), 3.81±2.23 diseases, 4.29±3.60 medications or supplements, and good functional status (MMSE 29.0±1.5, Barthel Index 98.1±8.2, prevalence of Fried frailty phenotype 2.5%). During one-year follow-up, 34 subjects (21.3%; 95% confidence interval [CI] =14.9-27.6%) experienced CE: hospitalizations (13.8%; 95% CI=8.41-19.1), falls (9.38%; 95% CI=4.86-13.9), death (0.63%; 95% CI=0-1.85) and no institutionalization. A higher probability of CE was associated with age ≥70 years (P=0.018), taking any medication or supplements (P=0.007), usual pace gait speed ≤0.8 m/s (P=0.028) and TUG >9 s (P<0.002). TUG was the only independent measure predicting one-year CE occurrence (OR=1.22, 95% CI=1.07-1.40, P=0.003) in multivariate logistic regression. However, its predictive power was poor; the area under the receiver operating characteristic curve was 0.659 (95% CI 0.551-0.766, P=0.004) and Youden's J statistic for a TUG cut-off of 9.0 s was 0.261 (sensitivity 0.618 and specificity 0.643).

Conclusion

The TUG test was superior to frailty phenotype measures in predicting one-year incidence of a CE consisting of fall, hospitalization, institutionalization and death in a cohort of healthy-aging community-dwelling early-old adults, although its value as a stand-alone test was limited.

Physical Frailty and Fall Risk in Community-Dwelling Older Adults: A Cross-Sectional Study

Introduction

Frailty is a condition in older adults with decreased physical and cognitive performance that can affect health outcomes associated with fracture, disability, and falls. The aim of this study was to compare fall risk with different physical frailty statuses and investigate factors associated with fall risk in community-dwelling older adults.

Methods

The population studied included 367 older adults (mean age = 73.2 years ± 7.0; 237 females (64.6%) and 130 males (35.4%)) who live in Chiang Mai, Thailand. This study was of cross-sectional design. Fried's phenotype was used to screen the physical frailty status. The physiological profile assessment (PPA) was used to screen for fall risk. One-way ANOVA analysis was used to compare the fall risk between the different levels of frailty status. Linear regression analysis was used to assess the association between frailty status and fall risk.

Results

The prevalence of the frailty group was 8.7% and that of the prefrailty group was 76.8%. The three statuses of frailty identified were found to have different levels of risk of falling. The frailty group had a higher fall risk than the nonfrailty group and the prefrailty group. In addition, the nonfrailty group had a lower fall risk than the prefrailty group.

Conclusion

The frailty group had the highest fall risk in this cohort of older adults living in a community-dwelling facility. Therefore, it is important to assess the frailty status among older adults as it can be a predictor for fall risk. This assessment will therefore lead to a reduction in the rate of disability and death in the community.

Reliability, validity, interpretability and responsiveness of the DEMMI mobility index for Brazilian older hospitalized patients

AIM

To translate and adapt cross-culturally the De Morton Mobility Index from English to Brazilian Portuguese. Furthermore, to test the content validity, reliability, construct validity, interpretability and responsiveness for older hospitalized patients.

METHODS

After we carried out the translation and the cross-cultural adaptation of the De Morton Mobility Index and its administration instructions according to international guidelines, the content validity of De Morton Mobility Index was tested by experienced physiotherapists. In the sequence, the reliability, construct validity, interpretability and responsiveness were tested in a test-retest design with 93 older patients hospitalized in ward for clinical reasons. The reliability was tested by Cronbach's alpha coefficient (internal consistency), standard error measurement (agreement), and interclass correlation coefficients (intra and inter-examiner reliability). The construct validity was tested by Pearson's correlation between the De Morton Mobility Index score and the number of steps. Interpretability was analyzed by determining the minimum detectable change and the floor and ceiling effects (frequency of maximum and minimum scoring). Responsiveness was analyzed by effect size.

RESULTS

The Brazilian version of the De Morton Mobility Index was made and adapted. The internal consistency (α = 0.89), reliability intra-(ICC = 0.94) and inter-examiners (ICC = 0.82), agreement were all adequate. The De Morton Mobility Index is validity when correlated with number of steps (r = 0.46). Floor or ceiling effects (<15%) were not observed and the responsiveness was high (ES = 3.65).

CONCLUSION

The De Morton Mobility Index has shown adequate reliability, validity, interpretability and responsiveness for the evaluation of the mobility of older hospitalized patients.

The Tilburg Frailty Indicator (TFI): New Evidence for Its Validity

Objective

The Tilburg Frailty Indicator (TFI) is a self-report user-friendly questionnaire for assessing multidimensional frailty among community-dwelling older people. The main aim of this study is to re-evaluate the validity of the TFI, both cross-sectionally and longitudinally, focusing on the predictive value of the total TFI and its physical, psychological, and social domains for adverse outcomes disability, indicators of healthcare utilization, and falls.

Methods

The validity of the TFI was determined in a sample of 180 Dutch community-dwelling older people aged 70 years and older. The participants completed questionnaires including the TFI, the Groningen Activity Restriction Scale (GARS) for assessing disability, and questions with regard to health care utilization and falls in 2016 and again one year later.

Results

The physical and psychological domains of the TFI were significantly correlated as expected with adverse outcomes disability, many indicators of healthcare utilization, and falls. Regression analyses showed that physical frailty was mostly responsible for the effect of frailty on the adverse outcomes. The cross-sectional and longitudinal predictive validity of total frailty with respect to disability and receiving personal care was excellent, evidenced by Areas Under the Curves (AUCs) >0.8. In most cases, using the cut-off point 5 for total frailty ensured the best values for sensitivity and specificity.

Conclusion

The present study provided new, additional evidence for the validity of the TFI for assessing frailty in Dutch community-dwelling older people aiming to prevent or delay adverse outcomes, including disability.

Physical Function and Frailty for Predicting Adverse Outcomes in Older Primary Care Patients

OBJECTIVE

To explore the predictive ability of the Short Physical Performance Battery (SPPB), Late Life Function and Disability Instrument-Function component (LLFDI-function) and frailty phenotype, for falls, hospitalizations, emergency department (ED) visits, and low self-rated health (SRH) over 1 and 2 years in older adults.

DESIGN

Secondary analysis of data from a longitudinal study, the Boston Rehabilitative Impairment Study of the Elderly.

SETTING

Primary care.

PARTICIPANTS

Adults 65 years and older at risk for disability who completed ≥1 follow-up call (N=391).

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

We computed separate logistic regression models using the SPPB, LLFDI-function, and frailty phenotype as independent variables and falls, hospitalizations, ED visits, and SRH over 1 and 2 years as dependent variables. Receiver operating characteristic curves were constructed and the areas under the curves calculated.

RESULTS

Participants had a mean age of 76.5±7.1 years. The SPPB, LLFDI-function, and frailty phenotype all predicted hospitalizations and low SRH over a 1- and 2-year timeframe (odds ratio [OR] min-max, 1.35-1.51 and 1.67-3.07, respectively). Over 2 years, the SPPB predicted ED visits (OR, 1.28), and the LLFDI-function predicted falls (OR, 1.31). The LLFDI-function predicted low SRH better than the frailty phenotype over 1 year. There were no differences between the measures for any of the other outcomes.

CONCLUSIONS

The SPPB, LLFDI-function, and frailty phenotype had similar accuracy for predicting falls, hospitalizations, ED visits, and low SRH over 1 and 2 years among older primary care patients at risk for disability. As a result, when considering the optimal screening tool for older adults, the choice between a measure of function and frailty may ultimately depend on clinical preference and context.

Turkish version of the Tilburg Frailty Indicator

Background

Recently frailty has drawn significant interest as an important predictor of several clinically relevant outcomes. There is no widely accepted instrument for the assessment of frailty and most of the current ones evaluate only physical features. The Tilburg Frailty Indicator (TFI) is a valid and reliable instrument which enables multidimensional assessment of frailty. We aimed to adapt and evaluate the Turkish version of the TFI.

Methods

We translated and culturally adapted the English version of the TFI into Turkish using standard guidelines. We enrolled consecutive patients who were 70 years old or older and were admitted to our outpatient geriatrics clinic. We used Cronbach’s alpha values to evaluate the internal consistency and also assessed inter-observer and test–retest variability using intraclass correlation coefficient (ICC).

Results

The Cronbach’s alpha reliability coefficients of the instrument ranged from 0.65 to 0.72 and item-total correlation ranged between −0.05 and 0.57. There was a good agreement between two assessments (ICC=0.99) and between two observers (ICC=0.99).

Conclusion

We have shown the reliability of the Turkish version of the TFI as a tool to evaluate frailty in a multidimensional manner among the Turkish outpatient population.

Exploring the efficiency of the Tilburg Frailty Indicator: a review

Due to rapidly aging human populations, frailty has become an essential concept, as it identifies older people who have higher risk of adverse outcomes, such as disability, institutionalization, lower quality of life, and premature death. The Tilburg Frailty Indicator (TFI) is a user-friendly questionnaire based on a multidimensional approach to frailty, assessing physical, psychologic, and social aspects of human functioning. This review aims to explore the efficiency of the TFI in assessing frailty as a means to carry out research into the antecedents and consequences of frailty, and its use both in daily practice and for future intervention studies. Using a multidimensional approach to frailty, in contexts where health care professionals or researchers may have no time to interview or examine the client, we recommend employing the TFI because there is robust evidence of its reliability and validity and it is easy and quick to administer. More studies are needed to establish whether the TFI is suitable for intervention studies not only in the community, but also for specific groups such as patients in the hospital or admitted to an emergency department. We conclude that it is important to not only determine the deficits that frail older people may have, but also to assess their balancing strengths and resources. In order to be able to meet the individual needs of frail older persons, traditional and often fragmented elderly care should be developed toward a more proactive elderly care, in which frail older persons and their informal network are in charge.