Taking to bed. Rapid functional decline in an independently mobile older population living in an intermediate-care facility

The association between restricted activity and patient outcomes in older adults: systematic literature review and meta-analysis

BACKGROUND

Restricted activity is a potential early marker of declining health in older adults. Previous studies of this association with patient outcomes have been inconclusive. This review aimed to evaluate the extent to which restricted activity is associated with decline in health.

METHODS

A search was conducted for studies including people over 65 years old which investigated the association between measures of restricted activity and hospitalisation, cognitive decline, and mortality. Following data extraction by two reviewers, eligible studies were summarised using Inverse Variance Heterogeneity meta-analysis.

RESULTS

The search identified 8,434 unique publications, with 11 eligible studies. Three measures of restricted activity were identified: bed rest, restricted movement, and dependency for activities of daily living (ADL). Three studies looked at hospitalisations, with two finding a significant association with bed rest or restricted movement and one showing no evidence of an association. Restricted activity was associated with a significant increase in mortality across all three measures (bed rest odds ratio [OR] 6.34, 95%CI 2.51-16.02, I2 = 76%; restricted movement OR 5.38 95%CI 2.60-11.13, I2 = 69%; general ADL dependency OR 4.65 95%CI 2.25-9.26, I2 = 84%). The significant heterogeneity observed could not be explained by restricting the analysis by length of follow-up, or measure of restricted activity. No meta-analysis was conducted on the limited evidence for cognitive decline outcomes.

CONCLUSIONS

Limited studies have considered the prognostic value of restricted activity in terms of predicting future declining health. Current evidence suggests restricted activity is associated with hospitalisation and mortality, and therefore could identify a group for whom early intervention might be possible.

The frailty dilemma. Review of the predictive accuracy of major frailty scores

BACKGROUND

To identify frail elderly individuals, several index or scoring systems have been developed for research purposes. The practical value of these scores for screening and diagnostic use is uncertain.

AIM

The available scoring systems were reviewed to determine whether they can be used in daily practice.

METHODS

Literature study on relevant test instruments developed for the detection of frailty on the basis of theoretical views on the frailty concept. Data on sensitivity and specificity and predictive values were extracted.

RESULTS

Several (n=6) frailty scores were described with respect to their value as a screening or diagnostic test. Outcome of the selected test instruments is presented as a risk of negative health outcome when a test is positive. The reported AUCs of ROCs varied from 0.55 for functional decline in people admitted to an accident and emergency department to 0.87 for prediction of mortality on the basis of a co-morbidity score. As the prevalence of frailty and resulting negative health outcomes in published reports was low (5-41%), presented sensitivity and specificity values lead to low positive predictive values (6-49%) but reasonable negative predictive values (73-96%).

CONCLUSIONS

As the number of false positive values of most available tests is substantial, these frailty scores are of limited value for both screening and diagnostic purposes in daily practice. As diagnostic instruments they can best be used to exclude frailty. The false-positive rate of currently available tests is too high to allow major decisions on medical care to be made on the basis of a positive test.

Minimizing the use of restrictive devices in dementia patients at risk for falling

The accumulating empirical evidence demonstrates that restrictive devices can be removed without negative consequences. Most importantly, use of nonrestrictive measures has been correlated with positive patient outcomes and represents care that is dignified and safe for confused elders. Most of these nonrestrictive approaches promote mobility and functional recovery; however, testing of individual interventions is needed to further the science. As the research regarding restrictive devices has been translated into professional guidelines and regulatory standards, the prevalence of usage has declined dramatically. New institutional models of care discouraging routine use of restrictive devices also will foster innovative solutions to clinical problems associated with dementia.

Molecular-based therapeutic approaches in treatment of anorexia of aging and cancer cachexia

Loss of appetite, or anorexia, has profound implications for older persons, altering social interactions, reducing quality of life, and leading to weight loss with grave health consequences. Two conditions associated with anorexia considered in this article are the multidetermined anorexia of aging and the wasting syndrome termed cachexia induced by cancer. Nutritional interventions may have some benefit in the former, but are of limited value in the latter. Emerging studies at the molecular level relating to appetite regulation and energy balance may offer new approaches to arrest progressive weight loss in the anorexia of aging and cancer cachexia.

Thriving: a life span theory

There is a need for aging theories to become holistic and multidisciplinary with a life span focus. A theory is the construction of explicit explanations in accounting for empirical findings. A good gerontological theory integrates knowledge, tells how and why phenomena are related, leads to prediction, and provides process and understanding. In addition, a good theory must be holistic and take into account all that impacts on a person throughout a lifetime of aging. Based on these criteria, the authors created the Theory of Thriving, with a holistic life span perspective for studying people in their environments as they age. This article proposes a theory for studying people over time in a holistic, encompassing manner.

Frailty in older adults: evidence for a phenotype

BACKGROUND

Frailty is considered highly prevalent in old age and to confer high risk for falls, disability, hospitalization, and mortality. Frailty has been considered synonymous with disability, comorbidity, and other characteristics, but it is recognized that it may have a biologic basis and be a distinct clinical syndrome. A standardized definition has not yet been established.

METHODS

To develop and operationalize a phenotype of frailty in older adults and assess concurrent and predictive validity, the study used data from the Cardiovascular Health Study. Participants were 5,317 men and women 65 years and older (4,735 from an original cohort recruited in 1989-90 and 582 from an African American cohort recruited in 1992-93). Both cohorts received almost identical baseline evaluations and 7 and 4 years of follow-up, respectively, with annual examinations and surveillance for outcomes including incident disease, hospitalization, falls, disability, and mortality.

RESULTS

Frailty was defined as a clinical syndrome in which three or more of the following criteria were present: unintentional weight loss (10 lbs in past year), self-reported exhaustion, weakness (grip strength), slow walking speed, and low physical activity. The overall prevalence of frailty in this community-dwelling population was 6.9%; it increased with age and was greater in women than men. Four-year incidence was 7.2%. Frailty was associated with being African American, having lower education and income, poorer health, and having higher rates of comorbid chronic diseases and disability. There was overlap, but not concordance, in the cooccurrence of frailty, comorbidity, and disability. This frailty phenotype was independently predictive (over 3 years) of incident falls, worsening mobility or ADL disability, hospitalization, and death, with hazard ratios ranging from 1.82 to 4.46, unadjusted, and 1.29-2.24, adjusted for a number of health, disease, and social characteristics predictive of 5-year mortality. Intermediate frailty status, as indicated by the presence of one or two criteria, showed intermediate risk of these outcomes as well as increased risk of becoming frail over 3-4 years of follow-up (odds ratios for incident frailty = 4.51 unadjusted and 2.63 adjusted for covariates, compared to those with no frailty criteria at baseline).

CONCLUSIONS

This study provides a potential standardized definition for frailty in community-dwelling older adults and offers concurrent and predictive validity for the definition. It also finds that there is an intermediate stage identifying those at high risk of frailty. Finally, it provides evidence that frailty is not synonymous with either comorbidity or disability, but comorbidity is an etiologic risk factor for, and disability is an outcome of, frailty. This provides a potential basis for clinical assessment for those who are frail or at risk, and for future research to develop interventions for frailty based on a standardized ascertainment of frailty.

Immobilization effects on contractile properties of aging rat skeletal muscle

The effect of four weeks of ankle immobilization on muscle mass and in situ contractile properties of soleus (SOL), plantaris (PLA), and extensor digitorum longus (EDL) of 31- and 37-month-old (mo) Fisher 344/Brown Norway rats was examined. Following contractile tests, muscles were harvested, weighed, and analyzed for fiber type and fiber cross-sectional area. Body weights (g) were similar in both control (CON) groups (31 mo, 578 +/- 20; 37 mo, 553 +/- 26; mean +/- SE) and both immobilized (IM) groups (31 mo, 496 +/- 6; 37 mo, 461 +/- 15). Immobilization-related differences in peak tetanic tension (g) were less in 37 mo than 31 mo rats (age x treatment, p < 0.05) for SOL (31 mo, CON 156 +/- 11, IM 63 +/- 12; 37 mo, CON 70 +/- 6, IM 46 +/- 8), PLA (31 mo, CON 435 +/- 13, IM 239 +/- 40; 37 mo, CON 155 +/- 14, IM 152 +/- 20) and EDL (31 mo, CON 227 +/- 13, IM 139 +/- 17; 37 mo, CON 117 +/- 16, IM 108 +/- 4). Immobilization-related differences in muscle mass (mg) were smaller in 37 mo rats compared to 31 mo animals for SOL (31 mo, 206 +/- 14 vs 129 +/- 8, 37 mo, 148 +/- 5 vs 114 +/- 2, age x treatment p < 0.06) and PLA (31 mo, 409 +/- 14 vs 257 +/- 22, 37 mo, 234 +/- 17 vs 181 +/- 18, age x treatment p < 0.05), but immobilization-related muscle mass differences were similar in both age groups for EDL (31 mo, 178 +/- 7 vs 134 +/- 9; 37 mo, 157 +/- 10 vs 112 +/- 7). There were no immobilization-related changes in fiber type distribution in any of the three muscles studied in either age group. The results suggest that disuse-related change is diminished when superimposed on muscles that have already undergone marked age-related decline.

A clinical trial to reduce restraints in nursing homes

OBJECTIVE

To investigate the relative effects of two experimental interventions on the use of physical restraints.

DESIGN

Prospective 12-month clinical trial in which three nursing homes were randomly assigned to restraint education (RE), restraint education-with-consultation (REC), or control (C).

SETTING

Three voluntary nursing homes in the Philadelphia area providing both skilled and intermediate care.

PARTICIPANTS

A total of 643 nursing home residents over the age of 60 were enrolled at baseline, and 463 remained to completion (1 year).

INTERVENTIONS

Both RE and REC homes received intensive education by a masters-prepared gerontologic nurse to increase staff awareness of restraint hazards and knowledge about assessing and managing resident behaviors likely to lead to use of restraints. In addition, the REC home received 12 hours per week of unit-based nursing consultation to facilitate restraint reduction in residents with more complex conditions.

MEASUREMENTS

Restraint status was observed systematically at baseline, immediately after the 6-month intervention, and again at 9 and 12 months. Staff levels, psychoactive drug use, and injuries were also determined.

RESULTS

Compared with baseline, the REC home had a statistically significant reduction in restraint prevalence, whereas RE and C homes did not. At 9 months (3 months post-intervention), absolute decline in the percents restrained were 7% RE, 7% C, and 20% REC; at 12 months (6 months post-intervention) declines were 4% RE, 6% C, and 18% REC. However, relative to baseline, these declines represent an average reduction in restraint use of 23% RE, 11% C, and 56% REC. The differences in changes over time were consistently significant (P = .01), whether considering survivors or those present at each time point, and also when controlling for differences between groups at baseline. Further, given any change in restraint use, REC-residents were between 25% and 40% more likely than either RE or C residents to experience decreased restraint use. Results were achieved without increased staff, psychoactive drugs, or serious fall-related injuries.

CONCLUSION

A 6-month-long educational program combined with unit-based, resident-centered consultation can reduce use of physical restraints in nursing homes effectively and safely. Whether extending the intervention will achieve greater reduction is not known from these results.

Physical restraint use and falls in nursing home residents

OBJECTIVE

To examine the relationship between restraint use and falls while controlling for the effect of psychoactive drug use among nursing home residents, including subgroups of nursing home residents with high rates of restraint use and/or falls.

DESIGN

Secondary analysis of data from a longitudinal clinical trial designed to reduce restraint use.

SETTING

Three nursing homes.

PARTICIPANTS

Subjects (n = 322) were either restrained (n = 119) or never restrained (n = 203) at each observation point during a 9.5-month data collection period that preceded the intervention phase of the clinical trial.

MEASUREMENTS

We evaluated restraint status (independent variable) three times during the data collection period by direct observation over a 72-hour period. Incident reports documenting falls and fall-related injuries (dependent variables) were reviewed. Cognitive status was measured using the Folstein Mini-Mental State Exam and functional status (including ambulation status) by the Psychogeriatric Dependency Rating Scale. Psychoactive drug use profile was obtained through record review.

MAIN RESULTS

Using multiple logistic regression, we compared the effect of restraint use on fall risk between a confused ambulatory subgroup and the remaining sample and found a significant difference in the odds ratio for falls and recurrent falls (P = .02; chi-square = 5.24, df = 1; P = .003, chi-square = 9.12, df = 1). In the confused ambulatory subgroup, restraint use was associated with increased falls (odds ratio: 1.65, 95% CI: 0.69, 3.98) as well as recurrent fall risk (odds ratio: 2.46, 95% CI: 1.03, 5.88). Increased falls and recurrent fall risk was not observed in the remaining sample (falls odds ratio: 0.49, 95% CI: 0.28, 0.87; recurrent falls odds ratio: 0.42, 95% CI: 0.20, 0.91). One subgroup, the nonconfused ambulatory residents, were never restrained; after removing this subgroup, the confused ambulatory continued to be associated, though not significantly, with a higher risk of falls and injuries. Only nonconfused nonambulatory restraints were associated with a lower risk of all three outcomes: falls (odds ratio: 0.28, 95% CI: 0.05, 1.58), recurrent falls (odds ratio: 0.48, 95% CI: 0.05, 4.72), and injurious falls (odds ratio:0.42, 95% CI: 0.04, 4.01); these results, however, were not statistically significant. There was no evidence that the effect of restraint use on fall risk depended upon the use of psychoactive drugs (chi square = 4.43; df = 2, P = .11).

CONCLUSION

Restraints were not associated with a significantly lower risk of falls or injuries in subgroups of residents likely to be restrained. These findings support individualized assessment of fall risk rather than routine use of physical restraints for fall prevention. Researchers and clinicians should continue to focus efforts on developing a variety of approaches that reduce risk of falls and injuries and promote mobility rather than immobility.

Differential effects of reduced muscle use (hindlimb unweighting) on skeletal muscle with aging

The changes in hindlimb muscle mass, fiber area and contractile tension that occurred with two weeks of reduced weight-bearing (HU) were of greater magnitude in 6-month-old as opposed to 36-month-old rats. The pattern of change following HU for young and old animals differed, which may indicate that multiple mechanisms are responsible for the observed changes. The majority of old rats had difficulty with ambulation following unweighting, suggesting that the functional consequences of reduced weight-bearing are greater in old than in young animals. One hour of weight-bearing during HU attenuated the decline in SOL fiber atrophy, muscle mass and Po, but had no apparent effect on the GAST, PL or EDL. The reduction in Po with HU was not due, except for the old PL, to changes at the neuromuscular junction.

Characteristics of rural homebound older adults: a community-based study

OBJECTIVE

To determine the frequency and characteristics of homebound older adults in a rural community.

DESIGN

An epidemiological survey of an age-stratified random community sample.

SETTING

The rural mid-Monongahela Valley in Southwestern Pennsylvania.

PARTICIPANTS

A total of 878 noninstitutionalized persons aged 68 years and older, fluent in English, and with at least grade 6 education.

MEASUREMENTS

The frequency with which subjects left their homes, the Mini-Mental State Examination (MMSE) score, and additional information on demographics, self-reported health problems, health services utilization, IADLs, depression, and social support were measured.

RESULTS

10.3% of the sample was classified as homebound. In univariate analyses, being homebound was found to be associated significantly (P < .001) with being older, female, and widowed and with MMSE and IADL impairment, with more depressive symptoms and worse social supports, fair to poor self-rated general health, weight loss, and histories of stroke, angina, arthritis of the spine, and falls. In a multiple regression model, variables associated independently with homebound status were gender (odds ratio = 9.4, 95% confidence interval = 3.6 - 24.9), weight loss (OR = 3.7, CI = 1.7 - 8.2), IADL impairment (OR = 2.6, CI = 2.1 - 3.1), and depressive symptoms (OR = 2.1, CI = 1.3 - 3.2). Being homebound was also associated with recent acute hospitalization and use of home health and social services.

CONCLUSIONS

These data provide evidence that homebound older adults have a disproportionate share of morbidity and disability and suggest a sociodemographic and clinical profile to help identify those older people at risk of being or becoming homebound. They also point to the need for home-based health services for the older adults, particularly in medically underserved communities such as rural areas.

A mobile rehabilitation team program to assist patients in nursing homes rehabilitate and return to their homes

A slow-stream rehabilitation program for frail elderly patients was developed utilising nursing homes visited by a mobile rehabilitation team (MRT) based at the hospital from which these patients had been discharged following major illness. The nursing homes were able to provide physiotherapy and the MRT contributed medical, nursing, occupational therapy and social work support through weekly visits. The supported group and a control group (also discharged to nursing homes from the same hospital but unsupported) were matched for age, sex and ADL level. Outcomes for the two groups were compared and were significantly different. Of the supported group (N = 33), 64% (N = 21) were discharged home compared with only 9% (N = 2) of the 23 control subjects (chi2 = 15.6, df. = 1, P < 0.05). The potential for patient rehabilitation in a modestly supported nursing home was realised.