Prognostic factors in mobility disability among elderly patients in the emergency department: A single-center retrospective study

Aim

We aimed to evaluate the clinical characteristics and outcomes of elderly critically ill patients and identify prognostic factors for mobility disability at discharge.

Methods

This single-center, retrospective cohort study investigated the period from April 2020 to January 2021. Patients ≥75 years old transferred to our emergency department and admitted to the intensive care unit (ICU) or intermediate unit in our hospital were eligible. Demographics, clinical characteristics, nutritional indicators, and nutritional screening scores were collected from chart reviews and analyzed. The primary outcome was the prevalence of mobility disability, compared to that of no mobility disability.

Results

A total of 124 patients were included in this present study. Median age was 83.0 years (interquartile range [IQR], 79.8-87.0 years) and 48 patients (38.7%) were female. Fifty-two patients (41.9%) could not walk independently at discharge (mobility disability group). The remaining 72 patients were in the no mobility disability group. Multiple logistic regression analyses revealed clinical frailty scale (CFS) score ≥5 (odds ratio [OR] = 6.63, 95% confidence interval [CI] = 2.51-17.52, p < 0.001), SOFA score ≥6 (OR = 6.11, 95% CI = 1.57-23.77, p = 0.009), and neurological disorder as the main cause on admission (OR = 4.48, 95% CI = 1.52-13.20, p = 0.006) were independent and significant prognostic factors for mobility disability at discharge.

Conclusion

Among elderly patients admitted to the emergency department, CFS ≥5, SOFA ≥6, and neurological disorders were associated with mobility disability at hospital discharge.

Validity and Reliability of the Persian Version of Barriers to Physical Activity Questionnaire for People With Mobility Impairments

BACKGROUND

Although physical activity (PA) is an important determinant of health, physically disabled individuals tend to have a sedentary lifestyle. The Barriers to Physical Activity Questionnaire for People with Mobility Impairments (BPAQ-MI) is a self-report instrument evaluating PA barriers. This study was intended to evaluate the validity and reliability of the Persian version of BPAQ-MI (P-BPAQ-MI) and to report the prevalence and severity of PA barriers among Persian-speaking individuals.

METHODS

The translation and back translation of the BPAQ-MI was conducted according to an internationally accepted guideline and tested on 163 participants to assess its reliability and validity. Internal consistency and test-retest reliability were analyzed using Cronbach alpha and Spearman correlation coefficient. Convergent construct validity was established by comparing the scores of P-BPAQ-MI and The Baecke Habitual Physical Activity Questionnaire. Known-groups construct validity was assessed with regard to type of assistive device and sex of the individual. Prevalence and severity of the barriers were reported by computing the percentage and means of "yes" answers.

RESULTS

The P-BPAQ-MI domains demonstrated very good internal consistency (Cronbach alpha of .77-.95) and excellent test-retest reliability (Spearman rho of .73-.96) with a significant inverse small correlation with Baecke Habitual Physical Activity Questionnaire indexes. The P-BPAQ-MI successfully discriminated between individuals with different assistive devices and sex. Community Built Environment barriers were the most prevalent and severe.

CONCLUSIONS

The P-BPAQ-MI is a valid and reliable instrument to assess the PA barriers of people with physical disability. The community barriers were the most frequently reported obstacles to PA.

Residential Mobility and Reasons for Moving Among People Living With Spinal Cord Injury: Results of a Multisite Survey Study

Background

Residential mobility after spinal cord injury (SCI) has not been extensively examined despite a growing interest in investigating the relationship between neighborhood exposures and community living outcomes.

Objectives

This study explores residential mobility patterns, the annual move rate, and reasons for moving among a community-living sample of adults with SCI.

Methods

A survey was conducted with 690 people at six SCI Model Systems centers in the United States between July 2017 and October 2020. The outcomes included move status in the past 12 months, move distance, and the primary reason for moving. A sample from the 2019 American Community Survey (ACS) 5-year pooled estimates was obtained for comparative analysis. Descriptive statistics were used to summarize the distributions of the outcomes and differences between the samples.

Results

The annual move rate for adults with SCI was 16.4%, and most moves were within the same county (56.6%). Recent movers were more likely to be young adults, be newly injured, and have low socioeconomic status. Housing quality, accessibility, and family were more frequently reported motivations for moving compared to employment. Young adults more commonly moved for family and accessibility, whereas middle-aged adults more commonly moved for housing quality. No notable difference was observed in the annual move rate between the SCI and the general population samples.

Conclusion

These findings suggest an age-related pattern of residential relocation after SCI, which may be indicative an extended search for optimal living conditions that meet the housing and accessibility needs of this population.

The REtirement in ACTion exercise programme and its effects on elements of long term functionality in older adults

Background

The prevention of mobility-related disability amongst adults is a global healthcare priority. Cost-effective community-based strategies to improve physical function and independence in older adults with mobility limitations are needed. This study investigated the effectiveness of the REtirement in ACTion (REACT) exercise intervention on individual markers of physical function at 6-and 12-months.

Methods

The REACT multicentre randomised controlled trial assigned 777 older adults (female, 514; male 263) (mean age 77·6 [SD 6·8] years) with reduced lower limb physical functioning (Short Physical Performance Battery [SPPB] score 4-9) to receive brief healthy ageing advice or a 12-month, group-based, multimodal exercise programme delivered in local communities. Estimated differences in the three individual component scores of the SPPB (strength, balance, gait speed) and physical functional outcomes recorded at 6- and 12-months were assessed.

Results

The intervention group demonstrated significant improvements in strength (OR = 1.88, 95% CI = 1.36-2.59, p < 0.001) and balance (OR = 1.96, 95% CI = 1.39-2.67, p < 0.001) at 12-months, but not in gait speed (OR = 1.32, 95% CI = 0.91-1.90, p = 0.139). In comparison to the control group, at six-and 12-months, the intervention group reported statistically significant improvements in Mobility Assessment Tool-Short Form (MAT-SF), physical component score from SF-36 questionnaire, and strength and endurance items of subjectively reported physical activity (PASE 10-item). Greater than 75% adherence (attending ≥48 of the 64 exercise sessions delivered in 12-months) was associated with superior functional outcomes.

Conclusion

The REACT exercise programme provides local, regional and national service providers with an effective solution to increase muscle strength and balance in older adults at risk of mobility disability.

Effect of a physical activity intervention and frailty on frailty trajectory and major mobility disability

BACKGROUND

Physical activity (PA) interventions may reduce the burden of frailty and can prevent mobility disability for older adults. We explored whether a 2-year PA intervention would improve frailty trajectory, lead to clinically meaningful frailty changes (CMC), or impact major mobility disability (MMD) across baseline frailty levels.

METHODS

We analyzed data for 1635 community-dwelling participants who were 70-89 years old (mean baseline age [SD]: 78.9 [5.2] years, 67.2% female) from the Lifestyle Interventions and Independence Study. Participants were randomized to either PA or health education (HE) intervention. A 44-item frailty index (FI) was constructed at baseline and 0.5, 1, 1.5, and 2 years after baseline. CMC was defined as change in FI of ≥0.03. MMD was the inability to complete a 400 m-walk within 15 min without assistance. Mixed-effects models were used to estimate frailty trajectory and CMC. Cox regression models were used to determine whether the effect of PA on the composite of MMD or death differed by baseline FI.

RESULTS

Mean FI (SD) at baseline for both the PA and HE groups was 0.18 (0.10). Two years after baseline, mean FIs were 0.23 (0.12) for PA and 0.24 (0.12) for HE. The MMD rates were 30.1% (246/818) and 35.5% (290/817) for PA and HE, respectively. There was no time-by-intervention interaction for frailty trajectory or for CMC. Regarding the composite MMD and death, there was no FI-by-intervention interaction. Simple association analyses revealed that when baseline FI was centered at 0.15 or higher, the PA intervention was associated with lower risk of MMD or death compared to HE (HR [CI] range for FI ≥ 0.15: 0.65-0.81 [0.43-0.67, 0.90-0.98]).

CONCLUSION

Participants in both groups showed similar frailty trajectories and CMC. Those who were frailer benefitted more from the PA intervention regarding MMD and death and may be a focus of recruitments for future PA program.

Research-Driven Guidelines for Delivering Group Exercise Programs via Videoconferencing to Older Adults

Telehealth holds much potential for supporting older adults' physical and social health. In particular, telewellness interventions to support the physical and social wellness of older adults are needed to overcome participation barriers with in-person programs. This paper presents guidelines for delivering telewellness interventions to older adults, which were informed by a human factors approach to developing a Tele Tai Chi intervention for older adults with mobility disabilities, including reviewing user needs literature and conducting user-centered needs assessment research. From these findings, we developed a protocol and support materials for delivering a telewellness intervention and conducted a feasibility study. We also established an adaptation committee to provide recommendations on the intervention. The outcome of our human factors approach was the establishment of research-driven design guidelines for delivering group exercise programs to older adults using videoconferencing. The guidelines provide direction for designing a telewellness protocol, supporting remote participation, and promoting socialization and engagement. These guidelines can be used to deliver interventions that increase access to socially-engaging, physical activity programs for older adults, which can ultimately help support their physical health, mental health, and quality of life.

Implications of Physical Access Barriers for Breast Cancer Diagnosis and Treatment in Women with Mobility Disability

OBJECTIVE

More than 30 years since enactment of the Americans with Disabilities Act, people with disability continue to face physical access barriers, notably inaccessible medical diagnostic equipment, in clinical settings. Access barriers affect breast cancer screening and treatment for women with disability.

METHODS

We used standard diagnosis codes and natural language processing to screen electronic health records (EHRs) in a digital data repository from a large healthcare delivery system for patients with pre-existing mobility disability diagnosed with breast cancer between 2005-2017. We reviewed EHRs of 20 patients, using conventional content analysis to examine breast cancer diagnosis and treatment experiences.

RESULTS

Clinicians noted challenges positioning patients for routine procedures including manual breast exam, screening mammography, and breast biopsies. Given challenges accommodating disability for adjuvant therapies, mastectomy was favored over breast-conserving options despite early stages of diagnosis. Notations contained little information about proactive problem-solving for arranging accommodations.

CONCLUSIONS

Notations described physical access barriers for breast cancer detection and treatment, with limited planning for mitigating barriers. Despite 2017 promulgation of federal Standards for Accessible Medical Diagnostic Equipment, implementing these standards requires further rulemaking.

A Physical Therapy Mobility Checkup for Older Adults: Feasibility and Participant Preferences From a Discrete Choice Experiment

PURPOSE

Physical performance measures, like walking speed, identify and predict preclinical mobility disability but are rarely used in routine medical care. A preventive model of care called Mobility Checkup is being designed to reduce mobility disability in older adults. This study had two purposes: 1) determine feasibility and outcomes of the Mobility Checkup, and 2) identify preferences of older adults regarding this model of care using a discrete choice experiment.

METHODS

Adults over 55 years of age were recruited from the community. In the study's first phase, participants completed a Mobility Checkup, with feasibility evaluated using 6 criteria. In the second phase, a new sample of older adults (>55 years old) were educated about the Mobility Checkup and then completed a discrete choice experiment to determine their preferences regarding 4 attributes of this care model: cost, visit duration, desired education topic, and style of educational graphic.

RESULTS

Each study phase was completed by 31 participants. Of the 6 feasibility criteria, 5 were met. Visit duration exceeded the 60-minute criteria for 13 of the 31 participants. Still, 91% of participants were very satisfied with the Mobility Checkup. Ability to transition positions identified preclinical mobility disability most frequently. A 30-minute visit with no out-of-pocket cost was deemed preferred.

CONCLUSIONS

Older adults value knowing what physical performance measurements predict about their general health. Transitions should be evaluated as part of a Mobility Checkup for older adults. Clearly conveyed cost of health care service is important to older adult consumers.

Prevalence of frailty and mobility disability in older people living in retirement villages

OBJECTIVE

To determine the prevalence rates of frail, prefrail, robust and mobility disabled older adults living in retirement villages within regional Victoria, Australia.

METHODS

This cross-sectional, observational study invited residents of retirement villages to complete the self-report questionnaires Fried Frailty Phenotype and Frail Non-Disabled screening tool to classify respondents as frail, prefrail, robust and/or mobility disabled.

RESULTS

From 212 respondents, prevalence rates of frail and prefrail status were 34% and 35%, respectively. A fifth (20%) of residents were mobility disabled. The prevalence of residents classified as frail or prefrail (ie, not robust) was higher in women (74%) than in men (58%). Classification as not robust increased with increasing age.

CONCLUSIONS

This study is the first to estimate prevalence rates of frailty and mobility disability in retirement village residents in regional Australia. Findings from this study have potential to inform the development of facilities and programs to support people living in this setting.

Risk Factors for Mobility Decline in Community-Dwelling Older Adults: A Systematic Literature Review

Mobility is essential to maintaining independence for older adults. This systematic review aimed to summarize evidence about self-reported risk factors for self-reported mobility decline; and to provide an overview of published prognostic models for self-reported mobility decline among community-dwelling older adults. Databases were searched from inception to June 2, 2020. Studies were screened by two independent reviewers who extracted data and assessed study quality. Sixty-one studies (45,187 participants) were included, providing information on 107 risk factors. High-quality evidence and moderate/large effect sizes for the association with mobility decline were found for older age beyond 75 years, the presence of widespread pain, and mobility modifications. Moderate-high quality evidence and small effect sizes were found for a further 21 factors. Three model development studies demonstrated acceptable model performance, limited by high risk of bias. These findings should be considered in intervention development, and in developing a prediction instrument for practical application.

Declining energy predicts incident mobility disability and mortality risk in healthy older adults

BACKGROUND

The purpose was to examine whether longitudinal changes in self-reported energy predict incident mobility disability and mortality. We further explored whether changes in energy-related behaviors (physical activity, appetite, or sleep quality) would explain these associations.

METHODS

N = 2021 participants from the Health, Aging and Body Composition Study free from mobility disability and with at least three energy assessments from years 2 to 10.

MEASUREMENTS

The outcomes were time to first self-reported inability to walk a quarter of a mile (mobility disability) and death. Self-reported energy level (SEL) was a single-item indicator over the prior month, ranging from 0 to 10; person-specific slopes measured whether individuals increased or decreased in SEL across the total follow-up time (mean 7.09 years, +1.72, range 2-8 years). Potential energy-related mediators were baseline and change in self-reported physical activity, appetite, and sleep quality. Covariates were baseline levels and change in demographics, health characteristics and behaviors, tiredness, cognition, mood, and gait speed.

RESULTS

A total of 947 developed disability and 567 died over the study follow-up. A one-point change in SEL over the follow-up (or an average 0.125 points/year) was inversely associated with a 35% risk of incident mobility disability (hazard ratio = 0.65, 95% confidence interval [CI] = 0.55, 0.76, p < 0.001) and 35% risk of death (hazard ratio = 0.67, 95% CI = 0.42, 0.87, p = 0.003), independent of covariates. Potential energy-related mediators did not attenuate this association.

CONCLUSIONS

In this longitudinal analysis of community-dwelling older adults, energy decline was common and a significant independent predictor of disability risk and mortality.

Perspectives of Patients with Pre-existing Mobility Disability on the Process of Diagnosing Their Cancer

BACKGROUND

Mobility disability is the most common disability among adult Americans, estimated at 13.7% of the US population. Cancer prevalence is higher among people with mobility disability compared with the general population, yet people with disability experience disparities in cancer screening and treatment.

OBJECTIVE

We explored experiences of patients with mobility disability with the process of cancer diagnosis.

DESIGN

Open-ended individual interviews, which reached data saturation. Interviews were transcribed verbatim for conventional content analysis.

PARTICIPANTS

We interviewed 20 participants with pre-existing mobility disability that required the use of an assistive device or assistance with performance of activities of daily living and who were subsequently diagnosed with cancer (excluding melanoma).

KEY RESULTS

Concerns coalesced around five broad categories: inaccessibility of medical diagnostic equipment affecting the process of cancer diagnosis, attitudes of clinical staff about accommodating disability, dismissal of cancer signs/symptoms as emotional responses to chronic health conditions, misattributing cancer signs/symptoms to underlying disability, and attitudes about pursuing legal action for substandard care. Participants provided examples of how erroneous assumptions and potentially biased attitudes among clinicians interfered with the process of their cancer diagnosis, sometimes contributing to an insufficient workup and diagnostic delays.

CONCLUSIONS

Physical and attitudinal barriers affect the process of cancer diagnosis in people with mobility disability. Though people with mobility disability may be clinically complex, clinicians should be aware of the risks of diagnostic overshadowing (i.e., the misattribution of cancer signs/symptoms to underlying disability) and other erroneous assumptions that may affect timeliness of cancer diagnosis and quality of care. Further efforts, including educating clinicians about challenges in caring for persons with disability, should be considered to improve the process of cancer diagnosis for this population.

TRIAL REGISTRATION

N/A.

Associations Between Disability and Breast or Cervical Cancers, Accounting for Screening Disparities

INTRODUCTION

Studies suggest that women with disability experience disparities in routine, high-value screening services, including mammograms and Papanicolaou (Pap) tests. However, few studies have explored whether women with disability have higher risks than other women of developing breast or cervical cancers.

METHODS

The authors analyzed 2010, 2013, 2015, and 2018 National Health Interview Surveys, which involved civilian, noninstitutionalized US residents, and included supplemental surveys on cancer screening. The authors used self-reported functional status limitations to identify women without disability and women with movement difficulties (MDs) or complex activity limitations (CAL) predating breast or cervical cancer diagnoses. Multivariable models evaluated associations of disability status to cancer diagnosis, adjusting for other variables. Analyses used sampling weights, producing national estimates.

RESULTS

The sample included 66,641 women; 24.4% reported MD and 14.5% reported CAL. Compared with women without disability, women with pre-existing MD or CAL had significantly higher rates of breast cancer (2.2% vs. 3.5% and 3.6%, respectively) and cervical cancer (0.6% vs. 0.8% and 1.0%, respectively). Women with disability had significantly lower recent mammography and Pap test rates than women without disability. After adjusting for all covariates, the values for odds ratio (95% confidence interval) of pre-existing CAL for cancer diagnoses were 1.21 (1.01-1.46; P=0.04) for breast cancer and 1.43 (1.04-1.99; P=0.03) for cervical cancer.

CONCLUSIONS

Pre-existing disability is associated with a higher likelihood of breast and cervical cancer diagnoses, raising the urgency of eliminating disability disparities in mammography and Pap testing. Further research will need to explore the causes of these higher cancer rates.

Implementation of a Community Walking Program (Walk On!) for Functionally-Limited Older Adults

BACKGROUND

Walking interventions improve physical function, reduce fall risk, and prevent mobility disability-even in those with compromised walking ability. However, most prior studies have been conducted in controlled research settings, with no dissemination of an evidence-based walking program for older adults who have mobility limitations and/or are socially isolated.

OBJECTIVES

This study reports data on the feasibility and acceptability of a community-based walking program (Walk On!) for older adults who are functionally limited, and assesses changes in physical function among attendees. The program sessions focused on long-distance walking, and took place for one-hour, for two days/week, and for 12 weeks at a time.

DESIGN

Pilot implementation study.

SETTING

Local church in Winston-Salem, NC.

PARTICIPANTS

49 program participants; Measurements: Physical function battery and satisfaction survey data, as well as formative evaluation data from six attendees of a focus group, are reported.

RESULTS

The majority of the participants were >75 years (71%), female (65%), and presented with low levels of physical function (usual gait speed=0.79±0.16; 30.6% used an assistive device). Satisfaction with the program was high (100% would recommend it to others) and focus group results were overwhelmingly positive. Mean attendance to scheduled sessions was 77%±21%, and 63% of participants attended at least 75% of scheduled sessions (n=8 attended 100%). On average, participants improved their 6-min walk distance by 8.9%, their SPPB score by 15.4%, their timed-up-go time by 9.0%, and their usual gait speed by 11.4%.

CONCLUSION

The results of the initial evaluation of Walk On! show high feasibility and acceptability of the program, as well as efficacy for improving physical function. Further research is needed to evaluate a delivery method for wider implementation of the program and to definitively test its effectiveness for improving function and other health benefits.

Sarcopenia Definition: The Position Statements of the Sarcopenia Definition and Outcomes Consortium

OBJECTIVES

To develop an evidence-based definition of sarcopenia that can facilitate identification of older adults at risk for clinically relevant outcomes (eg, self-reported mobility limitation, falls, fractures, and mortality), the Sarcopenia Definition and Outcomes Consortium (SDOC) crafted a set of position statements informed by a literature review and SDOC's analyses of eight epidemiologic studies, six randomized clinical trials, four cohort studies of special populations, and two nationally representative population-based studies.

METHODS

Thirteen position statements related to the putative components of a sarcopenia definition, informed by the SDOC analyses and literature synthesis, were reviewed by an independent international expert panel (panel) iteratively and voted on by the panel during the Sarcopenia Position Statement Conference. Four position statements related to grip strength, three to lean mass derived from dual-energy x-ray absorptiometry (DXA), and four to gait speed; two were summary statements.

RESULTS

The SDOC analyses identified grip strength, either absolute or scaled to measures of body size, as an important discriminator of slowness. Both low grip strength and low usual gait speed independently predicted falls, self-reported mobility limitation, hip fractures, and mortality in community-dwelling older adults. Lean mass measured by DXA was not associated with incident adverse health-related outcomes in community-dwelling older adults with or without adjustment for body size.

CONCLUSION

The panel agreed that both weakness defined by low grip strength and slowness defined by low usual gait speed should be included in the definition of sarcopenia. These position statements offer a rational basis for an evidence-based definition of sarcopenia. The analyses that informed these position statements are summarized in this article and discussed in accompanying articles in this issue of the journal. J Am Geriatr Soc 68:1410-1418, 2020.

Plasma Soluble αKlotho, Serum Fibroblast Growth Factor 23, and Mobility Disability in Community-Dwelling Older Adults

CONTEXT

αKlotho is a hormone and co-receptor for fibroblast growth factor 23 (FGF23), a hormone that downregulates active vitamin D synthesis and promotes phosphate excretion. Low αKlotho and high FGF23 occur in chronic kidney disease (CKD).

OBJECTIVE

We aimed to assess the relationships of αKlotho and FGF23 with mobility disability in community-dwelling older adults.

DESIGN AND SETTING

We estimated associations of plasma-soluble αKlotho and serum FGF23 concentrations with mobility disability over 6 years. Additional analyses was stratified by CKD.

PARTICIPANTS

Participants included 2751 adults (25.0% with CKD), aged 71 to 80 years, from the 1998 to 1999 Health, Aging, and Body Composition Study visit.

MAIN OUTCOME MEASURES

Walking disability and stair climb disability were defined as self-reported "a lot of difficulty" or an inability to walk a quarter mile and climb 10 stairs, respectively.

RESULTS

Median (interquartile range [IQR]) serum FGF23 and plasma soluble αKlotho concentrations were 46.6 (36.7, 60.2) pg/mL and 630.4 (478.4, 816.0) pg/mL, respectively. After adjustment, higher αKlotho concentrations were associated with lower walking disability rates (Rate Ratio [RR] highest vs. lowest tertile = 0.74; 95% confidence interval l [CI] = 0.62, 0.89; P = 0.003). Higher FGF23 concentrations were associated with higher walking disability rates (RR highest vs. lowest tertile = 1.24; 95%CI = 1.03, 1.50; P = 0.005). Overall, higher αKlotho combined with lower FGF23 was associated with the lowest walking disability rates (P for interaction = 0.023). Stair climb disability findings were inconsistent. No interactions with CKD were statistically significant (P for interaction > 0.10).

CONCLUSIONS

Higher plasma soluble αKlotho and lower serum FGF23 concentrations were associated with lower walking disability rates in community-dwelling older adults, particularly those without CKD.

Comparing Longitudinal Sarcopenia Trends by Definitions Across Men and Women After Hip Fracture

OBJECTIVES

While sarcopenia is prevalent after hip fracture in the acute postfracture period, little is known about the prevalence after discharge. This study assessed longitudinal trends in sarcopenia prevalence over 12 months after hip fracture using three different operational definitions.

DESIGN

Prospective observational study.

SETTING

Baltimore Hip Studies seventh cohort.

PARTICIPANTS

A total of 82 men and 78 women, aged 65 years and older, with surgical repair of a nonpathological hip fracture.

MEASUREMENTS

Baseline assessment included a dual-energy X-ray absorptiometry scan and interview. Follow-up assessments, which additionally included performance measures, occurred 2, 6, and 12 months after admission. Using these measures, three sarcopenia definitions were assessed over the year following hip fracture: European Working Group on Sarcopenia in Older Persons (EWGSOP), International Working Group on Sarcopenia (IWGS), and Foundation for the National Institutes of Health (FNIH).

RESULTS

EWGSOP and IWGS provided the highest prevalence of sarcopenia (62%-69% in men, 42%-62% in women), while prevalence by FNIH was much lower for men (15%-19%) and women (5%-12%). For both men and women, the agreement between EWGSOP and IWGS definitions was excellent, and FNIH showed poor agreement with them, supported by various statistical measures across first-year follow-up. Prevalence was stable over time in men by all definitions, while the prevalence in women by FNIH was lowest at 2 months, significantly increased at 6 months (P = .03), and remained higher at 12 months. Whether sarcopenia prevalence differed significantly by sex varied by time point and definition; however, when different, men had a higher prevalence than women (P < .05). While some participants recovered from sarcopenia over time, some also became newly sarcopenic.

CONCLUSION

The prevalence of sarcopenia after fracture differed greatly for EWGSOP and IWGS compared to FNIH. Overall, there appeared to be no reduction in sarcopenia over the year after hip fracture, regardless of definition. Future research should examine the relationship between sarcopenia prevalence and functional recovery. J Am Geriatr Soc 68:1537-1544, 2020.

Plasma proteomic signature of the risk of developing mobility disability: A 9-year follow-up

INTRODUCTION

Mobility disability is a powerful indicator of poor health in older adults. The biological and pathophysiological mechanism underlying the development of mobility disability remains unknown. This study conducted a data-driven discovery phase investigation to identify plasma proteins that predict the incidence of mobility disability in community-dwelling older adults without mobility disability at baseline.

METHODS

We investigated 660 women and men, aged 71.9 ± 6.0 (60-94) years, who participated in the Invecchiare in Chianti, "Aging in the Chianti Area" study and completed the 400-m walk at fast pace (400-m walk) at enrollment. Median follow-up time was 8.57 [interquartile, 3.20-9.08] years. SOMAscan technology was used to measure 1,301 plasma proteins at enrollment. The incident of mobility disability was defined as inability to complete the 400-m walk. Protein-specific Cox proportional hazard model was adjusted for sex, age, and other important covariates.

RESULTS

Plasma levels of 75 proteins predicted mobility disability (p < .05). Significant proteins were enriched for the KEGG "PI3K-Akt signaling," "phagosomes," and "cytokine-cytokine receptor interaction" pathways. After multiple comparison adjustment, plasma cathepsin S (CTSS; hazard ratio [HR] 1.33, 95% CI: 1.17, 1.51, q = 0.007), growth/differentiation factor 15 (GDF15; HR: 1.45, 95% CI: 1.23, 1.72, q = 0.007), and thrombospondin-2 (THBS2; HR: 1.44, 95% CI: 1.22, 1.69, q = 0.007) remained significantly associated with high risk of losing mobility.

CONCLUSION

CTSS, GDF15, and THBS2 are novel blood biomarkers associated with new mobility disability in community-dwelling individuals. Overall, our analysis suggests that cellular senescence and inflammation should be targeted for prevention of mobility disability.

Impact and Lessons From the Lifestyle Interventions and Independence for Elders (LIFE) Clinical Trials of Physical Activity to Prevent Mobility Disability

BACKGROUND

Walking independently is basic to human functioning. The Lifestyle Interventions and Independence for Elders (LIFE) studies were developed to assess whether initiating physical activity could prevent major mobility disability (MMD) in sedentary older adults.

METHODS

We review the development and selected findings of the LIFE studies from 2000 through 2019, including the planning phase, the LIFE-Pilot Study, and the LIFE Study.

RESULTS

The planning phase and the LIFE-Pilot provided key information for the successful implementation of the LIFE Study. The LIFE Study, involving 1635 participants randomized at eight sites throughout the United States, showed that compared with health education, the physical activity program reduced the risk of the primary outcome of MMD (inability to walk 400 m: hazard ratio = 0.82; 95% confidence interval = 0.69-0.98; P = .03), and that the intervention was cost-effective. There were no significant effects on cognitive outcomes, cardiovascular events, or serious fall injuries. In addition, the LIFE studies provided relevant findings on a broad range of other outcomes, including health, frailty, behavioral outcomes, biomarkers, and imaging. To date, the LIFE studies have generated a legacy of 109 peer-reviewed publications, 19 ancillary studies, and 38 independently funded grants and clinical trials, and advanced the development of 59 early career scientists. Data and biological samples of the LIFE Study are now publicly available from a repository sponsored by the National Institute on Aging (https://agingresearchbiobank.nia.nih.gov).

CONCLUSIONS

The LIFE studies generated a wealth of important scientific findings and accelerated research in geriatrics and gerontology, benefiting the research community, trainees, clinicians, policy makers, and the general public. J Am Geriatr Soc 68:872-881, 2020.

The Effect of Smartphone Apps Versus Supervised Exercise on Physical Activity, Cardiorespiratory Fitness, and Body Composition Among Individuals With Mild-to-Moderate Mobility Disability: Randomized Controlled Trial

Background

Adequate levels of physical activity (PA) and good cardiorespiratory fitness (CRF) are associated with profound health benefits for individuals with mobility disability (MD). Despite the vast amount of research published in the field of PA interventions, little attention has been given to individuals with MD.

Objective

The aim of this study was to examine the efficacy of an app-based versus a supervised exercise and health coaching program to support adults with MD to increase levels of PA, CRF, and improve body composition.

Methods

Participants with self-perceived MD, aged 18 to 45 years, were included in this 12-week parallel-group randomized controlled trial and allocated at random to an app-based intervention, using commercially available apps—the Swedish Military training app (FMTK), the Acupedo walking app, and the LogMyFood food photography app—or a supervised exercise and health coaching intervention, including 1 weekly supervised exercise session and healthy lifestyle coaching. The primary outcome was the level of moderate-to-vigorous PA (MVPA) measured with accelerometers. Secondary outcomes included CRF measured by a submaximal test performed on a stationary bicycle and body composition measured by bioelectrical impedance. All outcomes were measured at baseline, 6 weeks, and 12 weeks. Linear mixed-effect models were used to assess the between-group differences, as well as the within-group changes through time, in each intervention group.

Results

A total of 110 participants with MD were randomized to an app-based intervention (n=55) or a supervised exercise and health intervention (n=55). The mean age of participants was 34.9 years (SD 6.1), and 81.8% (90/110) of the participants were women. CRF showed a moderate increase in both groups after 12 weeks—1.07 (95% CI –0.14 to 2.27) mL/kg/min increase in the app-based group and 1.76 (95% CI 0.70 to 2.83) mLkg/min increase in the supervised exercise group. However, the intention-to-treat analysis showed no significant differences between the groups in MVPA or CRF after 12 weeks. Waist circumference was significantly lower in the app-based intervention group.

Conclusions

Commercially available apps increased levels of CRF and improved body composition over 12 weeks to the same extent as supervised exercise sessions, showing that both are equally effective. However, neither the app-based intervention nor the supervised exercise intervention increased MVPA.

Trial Registration

International Standard Randomized Controlled Trial Number (ISRCTN): 22387524; http://isrctn.com/ISRCTN22387524.

Validity of Instrumented 360° Turn Test in Older Adults with Cognitive Impairment

AIMS

To examine concurrent and construct validity of inertial sensor 360°turn measures in relation with motion capture and mobility assessments in cognitively impaired older adults.

METHODS

Data was collected in 31 participants, mean age 85.2 (SD 5.2), during clockwise (CW) and counter clockwise (CCW) 360° turns using (1) APDM body-worn inertial sensors and (2) Qualisys 8-camera laboratory-based motion capture.

RESULTS

Absolute agreement between inertial sensor and motion capture measures was excellent for turn duration and turn peak velocity (ICC = 0.96-0.98). Strong to moderate correlations were present between inertial sensor turn measures and performance on the Timed Up and Go, Short Physical Performance Battery and 90-s Balance Test. ROC curve analysis of CCW 360° turn duration and turn peak velocity distinguished higher risk versus lower risk for mobility disability.

CONCLUSIONS

Inertial sensor 360° turn measures demonstrated concurrent and construct validity in relation to motion capture and mobility assessments.

Clinical Frailty Scale Score Before ICU Admission Is Associated With Mobility Disability in Septic Patients Receiving Early Rehabilitation

To clarify the relationship between mobility disability at the time of discharge from the ICU and clinical factors evaluated at ICU admission in septic patients.

Associations of Usual Pace and Complex Task Gait Speeds With Incident Mobility Disability

BACKGROUND/OBJECTIVES

To assess whether gait speed under complex conditions predicts long-term risk for mobility disability as well as or better than usual-pace gait speed.

DESIGN

Longitudinal cohort study.

SETTING/PARTICIPANTS

Subsample of Health Aging and Body Composition study with follow-up from 2002 to 2003 to 2010 to 2011, including 337 community-dwelling adults (mean age = 78.5 years, 50.7% female, 26.1% black).

MEASUREMENTS

Associations of gait speed measured under usual-pace, fast-pace, dual-task, and narrow-path conditions with mobility disability, defined by any self-reported difficulty walking ¼ mile assessed annually, were tested by Cox proportional hazard models adjusted for demographic and health characteristics. Models were fitted for each walking condition, and R² statistics were used to compare predictive value across models. Models were repeated for persistent mobility disability, defined as at least two consecutive years of mobility disability.

RESULTS

Mobility disability occurred in 204 (60.5%) participants over the 8-year follow-up. There was a lower hazard of developing mobility disability with faster gait speed under all conditions. Hazard ratios, confidence intervals, and R² of gait speed predicting mobility disability were similar across all four walking conditions (R² range = 0.22-0.27), but were strongest for dual-task gait speed (hazard ratio [95% confidence interval], R² of fully adjusted models = 0.81 [0.75-0.88], 0.27). Results were comparable for persistent mobility disability (R² range = 0.26-0.28).

CONCLUSION

Slower gait speed under both usual-pace and complex conditions may be a clinical indicator of future risk of mobility disability. These results support the call for increased use of gait speed measures in routine geriatric care. J Am Geriatr Soc 67:2072-2076, 2019.

To initiate the conversation - Public health nurses' experiences of working with obesity in persons with mobility disability

Aim

Developing a theory explaining how public health nurses accomplish and adapt counselling in lifestyle habits to decrease obesity in people with mobility disability.

Design

Empirical research ‐ qualitative.

Method

Classic grounded theory with face‐to‐face interviews, 2017–2018, using inductive approach to understand public health nurses' intervening experiences with obesity patients.

Results

To initiate the conversation emerged as the main concern meaning having difficulties initiating conversations about obesity with patients. Public health nurses’ facilitators to communicate lifestyle changes emerged as the pattern generating the theory, which consists of the categories; person‐centeredness in the situation, experience and knowledge, strengthening conditions, access to other professionals and prioritization in everyday work.

Conclusions

Public health nurses hesitate to raise topics of obesity in patients with mobility disability. They advocate increased integration with lifestyle changes in everyday work including multi‐professional cooperation. The implication is testing the emerged theory at primary health care centres.

Impact

Obesity is more common in people with mobility disability than in those without. There is a need to understand how public health nurses adapt counselling in lifestyle habits. Public health nurses hesitate to talk about obesity with patients in fear of offending anyone. Public health nurses did not distinguish between patients with or without mobility disability. Several facilitators could be helpful initiating conversation with the patients. Public health nurses need more time and resources to facilitate conversation with patients with mobility disability to counsel lifestyle changes.

'We only got Coca-Cola': Disability and the paradox of (dis)empowerment in Southeast Nigeria

BACKGROUND

Empowerment is the generic name for support services for persons with disability in Nigeria. In it, the elites of the society play leading roles. Special events such as anniversaries, Christmas seasons, wealthy people's birthdays, investiture of new titles and campaigns before general elections often provide occasions for empowerment programmes.

OBJECTIVES

This article explores discourses of empowerment of persons with disability in Southeast Nigeria. We concentrate on the relation between local elites and the disability community and how it impacts our understanding of empowerment. Conceptualising empowerment as worldmaking, and disability as something that is ambiguous, we challenge the assumption that the aim of empowerment of disabled people is to improve their (disabled people's) quality of life.

METHOD

This article relies on research data (collected between January 2014 and January 2017) comprising 72 interviews and participant observations from 27 persons with disability, and 13 social workers and senior government officials.

RESULTS

We conclude that discourses of empowerment of disabled people frame disability as loss and tend to conceal the personal stories and survival operations of disabled people.

CONCLUSION

Empowerment discourses ironically provide the platform for local power elites to 'ride' to fame on the backs of disabled to extend their influence in society. In the current neoliberal environment of unequal access to opportunities, disabled people must 'play along' as a survival strategy. Our qualitative data provide opportunities to reflect on the tensions between the 'local and the global', thus indicating how disability issues intersect with other wider questions.

Therapies for mobility disability in persons with multiple sclerosis

INTRODUCTION

Mobility disability is one of the most widespread and impactful consequences of multiple sclerosis (MS). Disease modifying drugs (DMDs) may delay the progression of disability over time; however, there is minimal evidence supporting the efficacy of DMDs for reversing mobility disability or restoring ambulatory function in persons with MS. Areas covered: This review outlines symptomatic pharmacologic and non-pharmacologic therapeutic approaches that target mobility disability with the goal of restoring and improving walking function. First, the efficacy of dalfampridine, currently the only Food and Drug Administration approved symptomatic pharmacologic agent that improves walking in persons with MS is described. Next, a review of the efficacy of non-pharmacologic therapies for improving walking, including exercise training, physical therapy, and gait training is given. Last, guidance on future research on mobility in MS is provided by emphasizing the importance of combinatory treatment approaches that include multiple intervention modalities, as the best treatment plan likely involves a comprehensive, multidisciplinary approach. Expert commentary: There has been an increased effort to develop symptom-specific treatments in MS that directly target mobility disability; however, more research is needed to determine the efficacy of these rehabilitative strategies alone and together for improving walking in persons with MS.

Gait Speed and Mobility Disability: Revisiting Meaningful Levels in Diverse Clinical Populations

OBJECTIVES

To investigate the heterogeneity of clinically meaningful levels of gait speed relative to self-reported mobility disability (SR-MD).

DESIGN

Five longitudinal studies with older adults in different health states (onset of acute event, presence of chronic condition, sedentary, community living) were used to explore the relationship between gait speed and SR-MD.

SETTING

Lifestyle Interventions and Independence for Elders Pilot (LIFE-P), LIFE, Trial of Angiotensin-Converting Enzyme Inhibition and Novel Cardiovascular Risk Factors (TRAIN), Baltimore Hip Fracture Study (BHS2), Invecchiare in Chianti (InCHIANTI).

PARTICIPANTS

Individuals aged 65 and older (N=3,540): sedentary, community dwelling (LIFE-P/LIFE), with hip fracture (BHS2), random population-based sample (InCHIANTI), high cardiovascular risk (TRAIN).

MEASUREMENTS

Usual-pace gait speed across 3 to 4 m and SR-MD, defined as inability to walk approximately 1 block or climb 1 flight of stairs.

RESULTS

The mean gait speed of participants without SR-MD was greater than 1.0 m/s in InCHIANTI and TRAIN, 0.79 m/s in LIFE-P/LIFE, and 0.46 m/sec in BHS2. Of individuals with SR-MD, mean gait speed was 0.08 m/s slower in LIFE-P/LIFE, 0.19 m/s slower in TRAIN, 0.22 m/s slower in BHS2, and 0.36 m/s slower in InCHIANTI. The optimal gait speed cutpoint for minimizing SR-MD misclassification rates ranged from 0.3 m/s in BHS2 to 1.0 m/s in TRAIN. In longitudinal analyses, development of SR-MD was dependent on initial gait speed and change in gait speed (p<.001).

CONCLUSION

The relationship between absolute levels of gait speed and SR-MD may be context specific, and there may be variations between populations. Across diverse clinical populations, clinical interpretations of how change in usual pace gait speed relates to development of SR-MD depend on where on the gait speed continuum change occurs.

Three-Year Changes in Physical Activity and Subsequent Loss of Ability to Walk 400 m in Older Adults: The InCHIANTI Study

We examined the associations of maintaining or increasing physical activity (PA) for a 3-yr follow-up with subsequent incident inability to complete the 400-m walk test (i.e., mobility disability) for 6 yrs of follow-up in older adults. This study included 421 participants 65 yrs and older. The 400-m walk test was assessed at baseline and at 3-, 6-, and 9-yr follow-up. Physical activity was self-reported through a 6-point rating scale at baseline and 3-yr follow-up. Three-year cumulative PA (i.e., average at baseline and at 3-yr follow-up) and its changes (i.e., from baseline to 3-yr follow-up) were linked to subsequent incidence of mobility disability for 6 yrs of follow-up (i.e., from 3- to 9-yr follow-up), after adjustment for potential covariates. After the 3-yr period, incidence of mobility disability for the subsequent 6 yrs of follow-up occurred in 129 participants. The odds ratio (95% confidence interval) of incident mobility disability associated with 1-category increase in cumulative PA was 0.63 (0.41-0.97, P = 0.036). The odds ratio (95% confidence interval) of incident mobility disability associated with 1-category increase in changes in PA was 0.56 (0.38-0.84, P = 0.005). Hence, maintaining or increasing PA levels is associated with a reduced risk of mobility disability among older adults.

Is Obesity More Than a Double Burden among People with Mobility Disability? The Effect of Obesity on HRQoL and Participation in Society

Obesity is more common in individuals with mobility disability than in those without this condition. Individuals with mobility disability also have lower health-related quality of life (HRQoL) and are limited in their participation in society. Therefore, this study aimed to investigate the body mass index (BMI) status and the association of overweight or obesity on HRQoL and participation in society among those with mobility disability in comparison to those without mobility disability. This cross-sectional study was based on a health survey conducted in Sweden in 2012 (n = 18,322; age, 18–64 years). Logistic regression with and without interaction analysis was applied. Effect modification by overweight status was significant for, moderate pain. For obesity, effect modification was seen for low general health, pain (moderate and severe), and not participating in work. BMI was higher among those with mobility disability, but no associations between overweight or obesity and HRQoL or participation in society were observed for those with mobility disability. Overweight and obesity did not add an additional burden to mobility disability, probably because mobility disability is associated with low HRQoL and low participation in society. Despite these results, population obesity prevention strategies are still needed.

Device-Measured Physical Activity As a Predictor of Disability in Mobility-Limited Older Adults

OBJECTIVES

To examine associations between objectively measured physical activity (PA) and incidence of major mobility disability (MMD) and persistent MMD (PMMD) in older adults in the Lifestyle Interventions and Independence for Elders (LIFE) Study.

DESIGN

Prospective cohort of individuals aged 65 and older undergoing structured PA intervention or health education.

SETTING

The LIFE Study was a multicenter (eight sites) randomized controlled trial designed to compare the efficacy of a long-term structured PA intervention with that of a health education (HE) program in reducing the incidence of MMD in mobility-limited older adults.

PARTICIPANTS

LIFE Study participants (n = 1,590) had a mean age±standard deviation of 78.9 ± 5.2, low levels of PA, and measured mobility-relevant functional impairment at baseline.

MEASUREMENTS

Activity data were collected using hip-worn 7-day accelerometers at baseline and 6, 12, and 24 months after randomization to test for associations with incident MMD and PMMD (≥2 consecutive instances of MMD).

RESULTS

At baseline, every 30 minutes spent being sedentary (<100 accelerometry counts per minute) was associated with higher rate of subsequent MMD (10%) and PMMD (11%) events. Every 500 steps taken was associated with lower rate of MMD (15%) and PMMD (18%). Similar associations were observed when fitting accelerometry-based PA as a time-dependent variable.

CONCLUSION

Accelerometry-based PA levels were strongly associated with MMD and PMMD events in older adults with limited mobility. These results support the importance of daily PA and lower amounts of sedentary time levels in this population and suggest that accelerometry may be a useful tool for assessing risk of mobility disability.

ENabling Reduction of Low-grade Inflammation in SEniors Pilot Study: Concept, Rationale, and Design

OBJECTIVES

To test two interventions to reduce interleukin (IL)-6 levels, an indicator of low-grade chronic inflammation and an independent risk factor for impaired mobility and slow walking speed in older adults.

DESIGN

The ENabling Reduction of low-Grade Inflammation in SEniors (ENRGISE) Pilot Study was a multicenter, double-blind, placebo-controlled randomized pilot trial of two interventions to reduce IL-6 levels.

SETTING

Five university-based research centers.

PARTICIPANTS

Target enrollment was 300 men and women aged 70 and older with an average plasma IL-6 level between 2.5 and 30 pg/mL measured twice at least 1 week apart. Participants had low to moderate physical function, defined as self-reported difficulty walking one-quarter of a mile or climbing a flight of stairs and usual walk speed of less than 1 m/s on a 4-m usual-pace walk.

INTERVENTION

Participants were randomized to losartan, omega-3 fish oil (ω-3), combined losartan and ω-3, or placebo. Randomization was stratified depending on eligibility for each group. A titration schedule was implemented to reach a dose that was safe and effective for IL-6 reduction. Maximal doses were 100 mg/d for losartan and 2.8 g/d for ω-3.

MEASUREMENTS

IL-6, walking speed over 400 m, physical function (Short Physical Performance Battery), other inflammatory markers, safety, tolerability, frailty domains, and maximal leg strength were measured.

RESULTS

Results from the ENRGISE Pilot Study will provide recruitment yields, feasibility, medication tolerance and adherence, and preliminary data to help justify a sample size for a more definitive randomized trial.

CONCLUSION

The ENRGISE Pilot Study will inform a larger subsequent trial that is expected to have important clinical and public health implications for the growing population of older adults with low-grade chronic inflammation and mobility limitations.

Hospitalizations During a Physical Activity Intervention in Older Adults at Risk of Mobility Disability: Analyses from the Lifestyle Interventions and Independence for Elders Randomized Clinical Trial

OBJECTIVES

To determine whether moderate-intensity physical activity (PA) and health education (HE) are differentially associated with categories of hospitalizations or subgroups of participants.

DESIGN

Multicenter randomized controlled trial in which participants were randomized to a PA or HE program for an average of 2.6 years.

SETTING

Eight field centers.

PARTICIPANTS

Sedentary men and women aged 70-89 with lower extremity physical limitations but able to walk 400-m in 15 minutes or less (N = 1,635).

INTERVENTIONS

Structured, moderate-intensity PA (n =  818) at a center (2×/wk) and at home (3-4×/wk) that included aerobic, strength, balance, and flexibility training or HE (n =  817) of educational workshops and upper extremity stretching exercises.

MEASUREMENTS

All-cause inpatient hospitalizations ascertained at 6-month intervals.

RESULTS

There were 1,458 hospitalizations (49.1% of PA, 44.4% of HE; risk difference = 4.68%, 95% confidence interval (CI) = -0.18-9.54; hazard ratio (HR) = 1.16, 95% CI = 1.00-1.34). The intervention effect on incident hospitalization did not differ according to race, sex, Short Physical Performance Battery score, age, or history of cardiovascular disease or diabetes mellitus. PA was associated with higher rates of hospitalization in the middle baseline gait speed category, than HE (<0.8 m/s: HR = 0.93, 95% CI = 0.76-1.14; 0.8-1.0 m/s: HR = 1.54, 95% CI = 1.23-1.94; >1.0 m/s: HR = 1.05, 95% CI = 0.67-1.65; interaction P = .005).

CONCLUSION

A PA program in older adults at risk for mobility disability did not lead to a different risk of specific types of hospitalizations than a HE program overall. Baseline gait speed may be a marker for risk of hospitalization during a PA intervention, because individuals with moderate baseline gait speed in the PA group had slightly higher rates of hospitalization than those in the HE group.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01072500.

Associations Between Self-Reported Physical Activity and Physical Performance Measures Over Time in Postmenopausal Women: The Women's Health Initiative

OBJECTIVES

To examine prospective associations between changes in physical activity (PA) and changes in physical performance measures (PPMs) over 6 years in older women.

DESIGN

Prospective cohort study.

SETTING

Forty clinical centers in the United States.

PARTICIPANTS

Women aged 65 and older (mean age 69.8) enrolled in the Women's Health Initiative Clinical Trials with gait speed, timed chair stand, grip strength, and self-reported recreational PA data assessed at baseline (1993-98) and follow-up Years 1, 3, and 6 (N = 5,092).

MEASUREMENTS

Mixed-effects linear regression models were used to determine the association between time-varying PA and change in each PPM. Potential interactions between time-varying PA and age (<70, ≥70) were also tested.

RESULTS

Significan, dose-response associations between PA and improvements in all PPMs were observed over the 6 years of follow-up after adjusting for important covariates. High PA groups (≥1,200 metabolic equivalent (MET)-min/wk) had stronger grip strength (0.48 kg greater; P < .01), more chair stands (0.35 more; P < .001), and faster gait speeds (0.06 m/s faster; P < .001) than sedentary women (<100 MET-min/wk). Higher PA levels were associated with a greater increase in chair stands over time in women aged 70 and older (P < .001) than in those younger than 70 (P_{interaction for age}  = .01).

CONCLUSION

In postmenopausal women, maintaining high PA levels over time is associated with better lower extremity function. These data support the view that regular PA plays an important role in maintaining functional status during aging in older women.

Catechol-O-Methyltransferase Genotype and Gait Speed Changes over 10 Years in Older Adults

OBJECTIVES

To determine the association between catechol-O-methyltransferase (COMT) genotype and 6-m walk time and to determine whether these associations are quadratic in nature, similar to previously reported U-shaped associations between dopamine and gait and cognition.

DESIGN

Prospective cohort study.

SETTING

Health, Aging and Body Composition Study.

PARTICIPANTS

Black (n = 850) and white (n = 1,352) men and women with a mean age of 73.5 ± 2.85 at baseline.

MEASUREMENTS

Mixed models were used to assess the association between the COMT genotype and 6-m walk time, cross-sectionally and longitudinally over 10 years. Models were assessed unstratified and stratified according to race because allele distributions were different between white and black participants.

RESULTS

There was a significant U-shaped association between COMT genotype and 6-m walk time: those with higher (Val/Val) and lower (Met/Met) dopamine slowed more over 10 years (0.22 ± 0.02 seconds per visit and 0.23 ± 0.02 seconds per visit, respectively) than those with the intermediate (Met/Val) dopamine (0.20 ± 0.02 seconds per visit) (P = .005). Stratified results showed a significant relationship in black (P = .01) but not white (P = .15) participants.

CONCLUSION

These findings indicate a role of dopaminergic regulation of gait speed in community-dwelling older adults and of prefrontal cortex involvement in gait performance. Future work should investigate the molecular integrity of dopaminergic networks and gait changes over time and structural changes in the brain with COMT and gait decline in older adults.

Towards a postponement of activities of daily living dependence and mobility limitations: Trends in healthy life years in old age in Sweden

AIMS

To investigate the development of healthy life expectancy from 65 years (HLE65) in Sweden in the period 1980-2011 using the health indicators activities of daily living (ADL) and mobility limitations within the framework of the postponement, compression and expansion theories.

METHODS

Sources of data for the HLE computations were Swedish national mortality statistics and the nationwide Swedish Surveys of Living Conditions, conducted biennially by Statistics Sweden since 1974. We used the Sullivan method for calculations of HLE and a decomposition into mortality and disability effects was made.

RESULTS

Life expectancy at age 65 (LE65) increased by 3.1 years for women and 4.0 years for men from 1980-1985 to 2006-2011. HLE65 calculated according to ADL and mobility limitations increased more rapidly than LE65 for both men and women ( p<0.05).

CONCLUSIONS

Our results for trends in the Swedish LE65 and HLE65, computed on the basis of ADL and mobility limitations and using the Swedish Surveys of Living Conditions study, are in line with the postponement hypothesis and there is also a tendency for compression. Thus the years with ADL dependence and mobility limitations are postponed to a higher age and the numbers of these years have decreased.

Accessibility of outpatient healthcare providers for wheelchair users: Pilot study

The Americans with Disabilities Act (ADA) requires full and equal access to healthcare services and facilities, yet studies indicate individuals with mobility disabilities receive less than thorough care as a result of ADA noncompliance. The objective of our pilot study was to assess ADA compliance within a convenience sample of healthcare clinics affiliated with a statewide healthcare network. Site assessments based on the ADA Accessibility Guidelines for Buildings and Facilities were performed at 30 primary care and specialty care clinics. Clinical managers completed a questionnaire on standard practices for examining and treating patients whose primary means of mobility is a wheelchair. We found a majority of restrooms (83%) and examination rooms (93%) were noncompliant with one or more ADA requirements. Seventy percent of clinical managers reported not owning a height-adjustable examination table or wheelchair accessible weight scale. Furthermore, patients were examined in their wheelchairs (70%-87%), asked to bring someone to assist with transfers (30%), or referred elsewhere due to an inaccessible clinic (6%). These methods of accommodation are not compliant with the ADA. We recommend clinics conduct ADA self-assessments and provide training for clinical staff on the ADA and requirements for accommodating individuals with mobility disabilities.

Prevalence of metabolic syndrome and its association with physical capacity, disability, and self-rated health in Lifestyle Interventions and Independence for Elders Study participants

OBJECTIVES

To evaluate the prevalence of metabolic syndrome (MetS) and its association with physical capacity, disability, and self-rated health in older adults at high risk of mobility disability, including those with and without diabetes mellitus.

DESIGN

Cross-sectional analysis.

SETTING

Lifestyle Interventions and Independence for Elders (LIFE) Study.

PARTICIPANTS

Community-dwelling sedentary adults aged 70 to 89 at high risk of mobility disability (Short Physical Performance Battery (SPPB) score ≤9; mean 7.4 ± 1.6) (N = 1,535).

MEASUREMENTS

Metabolic syndrome was defined according to the 2009 multiagency harmonized criteria; outcomes were physical capacity (400-m walk time, grip strength, SPPB score), disability (composite 19-item score), and self-rated health (5-point scale ranging from excellent to poor).

RESULTS

The prevalence of MetS was 49.8% in the overall sample (83.2% of those with diabetes mellitus, 38.1% of those without). MetS was associated with stronger grip strength (mean difference (Δ) = 1.2 kg, P = .01) in the overall sample and in participants without diabetes mellitus and with poorer self-rated health (Δ = 0.1 kg, P < .001) in the overall sample only. No significant differences were found in 400-m walk time, SPPB score, or disability score between participants with and without MetS, in the overall sample or diabetes mellitus subgroups.

CONCLUSION

Metabolic dysfunction is highly prevalent in older adults at risk of mobility disability, yet consistent associations were not observed between MetS and walking speed, lower extremity function, or self-reported disability after adjusting for known and potential confounders. Longitudinal studies are needed to investigate whether MetS accelerates declines in functional status in high-risk older adults and to inform clinical and public health interventions aimed at preventing or delaying disability in this group.

Restricting back pain and subsequent mobility disability in community-living older persons

OBJECTIVES

To evaluate the relationship between back pain severe enough to restrict activity (restricting back pain) and subsequent mobility disability in community-living older persons.

DESIGN

Prospective cohort study.

SETTING

Greater New Haven, Connecticut.

PARTICIPANTS

Community-living men and women aged 70 and older (n = 709).

MEASUREMENTS

Restricting back pain and mobility disability (defined as needing help with or unable to walk one-quarter of a mile, climb a flight of stairs, or lift and carry 10 pounds) were assessed during monthly telephone interviews for up to 159 months. The association between restricting back pain and subsequent mobility disability was evaluated using a recurrent-events Cox model. Secondary analyses evaluated the association between restricting back pain and mobility disability for two or more consecutive months (persistent mobility disability). Additional analyses were repeated in participants without baseline mobility disability.

RESULTS

The event rate for mobility disability was 7.26 per 100-person months (95% confidence interval (CI) = 6.89-7.64). Mobility disability episodes lasted for a median of 2 months (interquartile range (IQR) 1-4). In a recurrent-event Cox regression analysis, after adjusting for 11 covariates, restricting back pain was strongly associated with mobility disability (hazard ratio (HR) = 3.23, 95% CI = 2.87-3.64). The association was maintained when the outcome was defined as persistent mobility disability (adjusted HR = 3.63, 95% CI = 3.15-4.20) and when participants with baseline mobility disability were omitted (adjusted HR = 3.71, 95% CI = 3.22-4.28).

CONCLUSION

Restricting back pain was strongly associated with mobility disability. Interventions that prevent or ameliorate restricting back pain may be effective for reducing the burden of mobility disability in older persons.

Impacts of mobility disability and high and increasing body mass index on health-related quality of life and participation in society: a population-based cohort study from Sweden

BACKGROUND

Increasing obesity in adults with mobility disability has become a considerable health problem, similar to the increasing trend of obesity in the general population. The aims of this study were to investigate the association of mobility disability with overweight status and obesity in a large population-based Swedish cohort of adults, and to investigate whether mobility disability, high body mass index (BMI), and increasing BMI over time are predictors of health-related quality of life and participation in society after 8 years of follow-up.

METHODS

The study cohort included 13,549 individuals aged 18-64 years who answered questions about mobility disability, weight, height, health-related quality of life and participation in society in the Stockholm Public Health Survey 2002 and 2010. The cohort was randomly selected from the population of Stockholm County, and divided into six subgroups based on data for mobility disability and overweight status. Multiple binary logistic regression analyses were performed to assess the likelihood for low health-related quality of life and lack of participation.

RESULTS

Respondents with mobility disability had a higher mean BMI than those without mobility disability. Respondents both with and without mobility disability increased in BMI, but with no significant difference in the longitudinal changes (mean difference: 0.078; 95% CI: -0.16 - 0.32). Presence of mobility disability increased the risk of low health-related quality of life and lack of participation in 2010, irrespective of low health-related quality of life and lack of participation in 2002. The risk of pain and low general health (parts of health-related quality of life) increased for every 5 units of higher BMI reported in 2010. In respondents without low general health at baseline, the risk of obtaining low general health increased for every 5 units of higher BMI in 2010 (OR:1.60; CI: 1.47 - 1.74).

CONCLUSIONS

The greatest risk of low general health after 8 years was observed for respondents with both mobility disability and high BMI. These results indicate the importance of working preventively with persons with mobility disability and overweight status or obesity based on the risk of further weight gain.

Physical activity and lower limb lymphedema among uterine cancer survivors

PURPOSE

Physical activity (PA) is known to provide physical and mental health benefits to uterine cancer survivors. However, it is unknown if PA is associated with lower limb lymphedema (LLL), an accumulation of protein-rich fluid in the lower limbs. Therefore, we sought to examine the association between PA and LLL in uterine cancer survivors, with a focus on walking.

METHODS

We conducted a cross-sectional study using mailed surveys among uterine cancer survivors who received care at a university-based cancer center. We asked about PA, walking, and LLL symptoms using validated self-report questionnaires. PA was calculated using MET-hours per week, and walking was calculated using blocks per day.

RESULTS

The response rate to our survey was 43%. Among the 213 uterine cancer survivors in our survey, 36% were classified as having LLL. Compared with participants who reported <3 MET · h · wk of PA, participants who reported ≥ 18.0 MET · h · wk of PA had an odds ratio of LLL of 0.32 (95% confidence interval, 0.15-0.69; P trend = 0.003). Stratified analyses suggested the association between PA and LLL existed only among women with body mass index (BMI) <30 kg · m (P trend = 0.007) compared with women with BMI ≥ 30 kg · m (P trend = 0.47). Compared with participants who reported <4.0 blocks per day of walking, participants who reported ≥ 12 blocks per day of walking had an odds ratio of LLL of 0.19 (95% confidence interval, 0.09-0.43; P trend < 0.0001). Stratified analyses suggested the association between walking and LLL was similar among women with BMI <30 kg · m (P trend = 0.007) and women with BMI ≥ 30 kg · m (P trend = 0.03).

CONCLUSION

Participation in higher levels of PA or walking is associated with reduced proportions of LLL in dose-response fashion. These findings should be interpreted as preliminary and should be investigated in future studies.

Body mass index patterns following dysvascular lower extremity amputation

PURPOSE

Using preliminary data, we examined: (i) patterns of body mass index (BMI) over the year following amputation by amputation level and (ii) the association between BMI and mobility and prosthetic device use.

METHOD

Patients from three medical centers undergoing dysvascular amputation (N = 87; M age = 62) participated in interviews pre-surgically and at 6 weeks, 4 months, and 12 months following amputation. The main outcome was self-reported BMI, adjusting for limb weight lost due to amputation. Additional outcomes were mobility and time spent using and walking in a prosthetic device.

RESULTS

Adjusted BMI slightly decreased at 6 weeks (pre-surgery M = 31.2; 6 weeks M = 30.3) and 4 months (M = 30.7) but exceeded baseline levels by 12 months (M = 31.7). There were no significant BMI differences by amputation level. In multivariable analyses, higher pre-surgical BMI was associated with fewer hours of prosthetic device walking at month 4 (β = -0.49) and poorer overall mobility at month 12 (β = -0.22).

CONCLUSIONS

BMI increased at one year following amputation surgery. Higher pre-surgical BMI was associated with poorer mobility and prosthetic device use. Interventions are needed to prevent excess weight gain in the year following amputation.

IMPLICATIONS FOR REHABILITATION

• People undergoing lower-extremity amputation have high rates of overweight and obesity and continue to gain weight in the year following amputation. • Objective assessment of body mass index (both with and without a prosthetic device) and waist circumference would help future research efforts. • Targeting weight loss post-amputation could improve the health of people with lower-extremity amputations.

Respiratory impairment in older persons: when less means more

BACKGROUND

Among older persons, within the clinical context of respiratory symptoms and mobility, evidence suggests that improvements are warranted regarding the current approach for identifying respiratory impairment (ie, a reduction in pulmonary function).

METHODS

Among 3583 white participants aged 65 to 80 years (Cardiovascular Health Study), we calculated the prevalence of respiratory impairment using the current spirometric standard from the Global Initiative for Obstructive Lung Disease (GOLD) and an alternative spirometric approach termed "lambda-mu-sigma" (LMS). Results for GOLD- and LMS-defined respiratory impairment were evaluated for their (cross-sectional) association with respiratory symptoms and gait speed, and for the 5-year cumulative incidence probability of mobility disability.

RESULTS

The prevalence of respiratory impairment was 49.7% (1780/3583) when using the GOLD and 23.2% (831/3583) when using LMS. Differences in prevalence were most evident among participants who had no respiratory symptoms, with respiratory impairment classified more often by the GOLD (38.1% [326/855]) than LMS (12.3% [105/855]), as well as among participants who had normal gait speed, with respiratory impairment classified more often by the GOLD (46.4% [1003/2164]) than LMS (19.3% [417/2164]). Conversely, the 5-year cumulative incidence probability of mobility disability for respiratory impairment was higher for LMS than GOLD (0.313 and 0.249 for never-smokers, and 0.352 and 0.289 for ever-smokers, respectively), but was similar for normal spirometry by LMS or GOLD (0.193 and 0.185 for never-smokers, and 0.219 and 0.216 for ever-smokers, respectively).

CONCLUSIONS

Among older persons, the LMS approach (vs the GOLD approach) classifies respiratory impairment less frequently in those who are asymptomatic and is more strongly associated with mobility disability.

Comorbid visual and cognitive impairment: relationship with disability status and self-rated health among older Singaporeans

The objective of this study was to examine the prevalence and consequences of coexisting vision and cognitive impairments in an Asian population. Data were collected from 4508 community-dwelling Singaporeans aged 60 years and older. Cognition was assessed by the Short Portable Mental Status Questionnaire whereas vision, disability, and self-rated health (SRH) were determined by self-report. Vision impairment was present in 902 (18.5%) participants and cognitive impairment in 835 (13.6%), with 232 (3.5%) participants experiencing both impairments. Persons with the comorbidity experienced higher odds of disability than persons with either single impairment. The association of vision impairment with SRH was stronger among women (odds ratio [OR] = 6.79, 95% confidence interval [CI] = 4.64-9.92) than among men (OR = 1.71, 95% CI = 1.21-2.41). Concurrent cognitive and vision impairment is prevalent in older Singaporeans and is associated with high rates of disability. Gender differences in vision-dependent roles may affect the patient-perceived impact of this comorbidity.

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

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

Successful skeletal aging: a marker of low fracture risk and longevity. The Study of Osteoporotic Fractures (SOF)

Successful aging is multidimensional, and many phenotypes have been proposed. We examined a biomarker of aging based on repeated measures of BMD for up to 15 yr and hypothesized that maintenance of BMD will be associated with low fracture risk and disability and improved survival. We studied 9704 women recruited at four U.S. clinical centers and enrolled in the Study of Osteoporotic Fractures, a longitudinal cohort study. Of these, 8224 women had at least one hip BMD measurement. Hip BMD was measured a maximum of five times over 15 yr. Random effects regression was used to determine a BMD slope for each subject. Three groups were formed-"maintained" BMD: slope >or=0, n = 724 (9%); "expected" BMD loss: slope <0 to <1 SD below mean, n = 6478 (79%); and "accelerated" BMD loss: slope >or=1 SD below mean, n = 1022 (12%). Cox proportional hazards models were used to compare the relative hazard (RH; 95% CI) of fracture, incident mobility disability, and mortality in the maintained and accelerated groups compared with the expected. A 1 SD decrease in the BMD slope was associated with an increased risk of all outcomes. In multivariate models, the RH of nonspine fracture was 0.81 (0.71-0.93) and of hip fracture was 0.36 (0.25-0.53) for women in the maintained compared with the expected group. The incidence of mobility disability was lower in the maintained versus expected group (RH = 0.70; 95% CI = 0.59-0.83), but this was largely explained by other factors. Women who experienced accelerated bone loss were more likely to develop disability (RH = 1.56; 95% CI: 1.33-1.84). Mortality risks were lower in the maintained compared with the expected group (RH = 0.49; 95% CI: 0.42-0.58). In conclusion, a subset of older women maintained their BMD up to 15 yr, suggesting that bone loss is not an inevitable consequence of aging. These women experienced a lower risk of fractures, disability, and mortality, suggesting that this phenotype may be a marker of successful aging.