Physical activity and quality of life in older adults.
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Biomedical subjects
D M Buchner
Publications and source records attributed to D M Buchner.
Continuous-scale physical functional performance in healthy older adults: a validation study.
OBJECTIVE: The continuous-scale physical functional performance test (CS-PFP) is an original instrument designed to provide a comprehensive, in-depth measure of physical function that reflects abilities in several separate physical domains. It is based on a concept of physical function as the integration of physiological capacity, physical performance, and psychosocial factors. SETTING: The test was administered under standard conditions in a hospital facility with a neighborhood setting. The CS-PFP consists of a battery of 15 everyday tasks, ranging from easy to demanding, that sample the physical domains of upper and lower body strength, upper body flexibility, balance and coordination, and endurance. Participants are told to work safely but at maximal effort, and physical functional performance was measured as weight, time, or distance. Scores were standardized and scaled 0 to 12. The test yields a total score and separate physical domain scores. DESIGN: The CS-PFP was evaluated using 148 older adults-78 community dwellers, 31 long-term care facility residents living independently, and 39 residents with some dependence. MAIN OUTCOME MEASURES: Maximal physical performance assessment included measures of maximal oxygen consumption (VO2max), isokinetic strength, range of motion, gait, and balance. Psychosocial factors were measured as self-defined health status using the Sickness Impact Profile (SIP), self-perceived function using the Health Survey (SF36), and Instrumental Activities of Daily Living (IADL). RESULTS: IADL scores were not significantly different among the groups. Test-retest correlations ranged from .84 to .97 and inter-rater reliability from .92 to .99 for the CS-PFP total and 5 domains. Internal consistency was high (Cronbach's alpha, .74 to .97). Both total and individual domain CS-PFP scores were significantly different for the three groups of study participants, increasing with higher levels of independence, supporting construct validity. CS-PFP domain scores were significantly correlated with measures of maximal physical performance (VO2max, strength, etc) and with physical but not emotional aspects of self-perceived function. CONCLUSION: The CS-PFP is a valid, reliable measure of physical function, applicable to a wide range of functional levels, and having minimal floor and ceiling effect. The total and physical domains may be used to evaluate, discriminate, and predict physical functional performance for both research and clinical purposes.
Activities of Daily Living↗
Evidence for a non-linear relationship between leg strength and gait speed.
Although the relationship between strength and physical performance in older adults is probably non-linear, few empirical studies have demonstrated that this is so. In a population-based sample of adults aged 60-96 years (n = 409), leg strength was measured in four muscle groups (knee extensor, knee flexor, ankle plantar flexor, ankle dorsiflexor) of both legs using an isokinetic dynamometer. A leg strength score was calculated as the sum of the four strength measurements in the right leg. Usual gait speed was measured over a 15.2 metre course. With a linear model, leg strength explained 17% of the variance in gait speed. Non-linear models (quadratic and inverse) explained significantly more variance (22%). The nature of the non-linear relationship was that, in stronger subjects, there was no association between strength and gait speed, while in weaker subjects, there was an association. Body weight and age also explained significant amounts of variance in gait speed, while sex and height did not. The results supported the hypothesis of a non-linear relationship between leg strength and gait speed that is similar for older men and women. This finding represents a mechanism for how small changes in physiological capacity may have substantial effects on performance in frail adults, while large changes in capacity have little or no effect in healthy adults.
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Factors associated with changes in gait speed in older adults.
BACKGROUND: The study addressed whether changes in gait speed in community-dwelling older adults were associated with changes in fitness (strength and aerobic capacity), physical health status, and/or depressive symptoms. METHODS: The study sample comprised 152 community-dwelling adults aged 68-85 who had participated in an exercise study. Study measures at baseline and 6-month follow-up included gait speed, a leg strength score, maximal aerobic capacity (VO2max), CES-Depression scale, and physical health status (SIP Physical Dimension). RESULTS: In cross-sectional regression analyses, leg strength, VO2max, weight, and the strength by VO2max interaction term were significant independent predictors of gait speed (R2 = 26%). Based upon the observed 7% increase in VO2max and 8% increase in strength in the exercise groups, the regression model predicted only a 2% (1.5 m/min) increase in gait speed, which did not differ significantly from the observed increase of 0% (.32 m/min). The strongest correlate of change in gait speed was change in CES-D scores (partial R = -.37). Change in physical health status also correlated with change in gait speed (partial R = -.28), while change in fitness did not. CONCLUSIONS: The results suggest, in the range of fitness of the study sample, that changes in gait speed are related to changes in depressive symptoms and physical health status, but not to modest changes in fitness. A model assuming nonlinear relationships may be appropriate for understanding how strength and aerobic capacity affect gait speed.
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The relationship of joint symptoms with exercise performance in older adults.
OBJECTIVES: The objective of this study is to determine if exercise increases joint symptoms in older adults with a history of arthritis or produces symptoms in older adults without such history. In addition, we examine whether joint symptoms explain the large observed variation in strength gain in older adults undergoing vigorous strength training exercise, and report the incidence of musculoskeletal injuries upon initiation of an exercise program. DESIGN: A population-based, single blinded, randomized controlled trial with three exercise groups and one control group. SETTING: A large urban health maintenance organization. PARTICIPANTS: Older men and women (N = 105) aged 68 to 85, with leg strength below the 50th percentile for their age, sex, height, and weight and without neuromuscular disease or active cardiovascular disease. INTERVENTIONS: Supervised exercise in 1-hour sessions, three times each week, for 24 to 26 weeks. One exercise group did strength training (ST) using weight machines (n = 25); another group did endurance training (ET) using stationary cycles (n = 25); and the third group did combined strength training and endurance training (ST+ET) (n = 25). The control group (n = 30) received no intervention. MEASUREMENTS: Strength was measured at the ankle, knee, hip, and elbow using an isokinetic dynamometer. Joint symptoms were rated on a 6-point scale (0 = none, 5 = severe). Arthritis severity was based on self-reported use of arthritis medication. Health status was measured with subscales of the SF-36 and Sickness Impact Profile (SIP). RESULTS: Joint symptoms fluctuated over time in all exercise groups, but they did not improve or worsen significantly in any group. The physical dimension of the SIP and SF-36 subscale scores, including Bodily Pain Scores, did not change over time in any group. Subjects with arthritis and joint symptoms gained as much strength with strength training as did subjects without joint symptoms. Adjustment for age, gender, baseline strength, adherence, and exercise group did not affect this finding. The rate of minor musculoskeletal injuries was 2.2 injuries per 1000 exercise hours. CONCLUSIONS: Moderate intensity stationary cycle exercise and vigorous intensity strength training do not appear to produce or exacerbate joint symptoms in older adults. Joint symptoms did not explain the large variation in gains in strength in older adults participating in a standardized strength training exercise program. Musculoskeletal injuries occurred relatively infrequently, and no major injuries occurred. In evaluating joint pain that occurs in older adults in well regulated exercise programs, clinicians should consider other etiologies before attributing pain to exercise per se.
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Effectiveness of geriatric evaluation and management: design of a study.
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A cross-sectional validation study of the FICSIT common data base static balance measures. Frailty and Injuries: Cooperative Studies of Intervention Techniques.
BACKGROUND: Two simple balance scales comprising three or four familiar tests of static balance were developed, and their validity and reliability are described. The scales were such that the relative difficulties of the basic tests were taken into consideration. METHODS: Using FICSIT data, Fisher's method was used to construct scales combining ability to maintain balance in parallel, semi-tandem, tandem, and one-legged stances. Reliability was inferred from the stability of the measure over 3-4 months. Construct validity was assessed by cross-sectional correlations. RESULTS: Test-retest reliability (over 3-4 months) was good (r = .66). Validity of the FICSIT-3 scale was suggested by its low correlation with age, its moderate to high correlations with physical function measures, and three balance assessment systems. The FICSIT-4 scale discriminated balance over a wide range of health status; the three-test scale had a substantial ceiling effect in community samples. CONCLUSION: A balance scale was developed that appears to have acceptable reliability, validity, and discriminant ability.
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Relationship between physical performance and self-perceived physical function.
OBJECTIVE: The objective of this study was to compare two methods of measuring physical function in subjects with a broad range of abilities and to evaluate the effects of cognitive, social, educational, and age factors on the relationship between the two methods. DESIGN: Multiple regression analysis was used to compare self-perceived (dependent variables) with performance measures (independent variables). Covariates included age, gender, Mini-Mental State Exam score, education, living status, and depression score. SETTING: Five community-dwelling and two nursing home sites. PARTICIPANTS: 417 community-dwelling subjects and 200 nursing home residents aged 62-98 years. MEASUREMENTS: Self-perceived physical function was assessed with the physical dimension summary score of the Sickness Impact Profile, which comprises three subscales: ambulation, mobility, and body care and movement. Physical performance was evaluated by self-selected gait speed, chair-stand time, maximal grip strength, and a balance score. RESULTS: Nursing home residents and community-dwellers were significantly different (P < .0001) in all variables except age and gender. Self-perceived and performance-based measures were moderately correlated, with a range from r = -.194 to r = -.625 (P < .05). Gait speed was the strongest independent predictor of self-perceived physical function in both groups. Symptoms of depression were also an independent predictor of self-perceived function in nursing home residents; subjects who had such symptoms report more self-perceived dysfunction than would be predicted based on performance tests. CONCLUSIONS: Self-selected gait speed is a global indicator of self-perceived physical function over a broad range of abilities. External determinants (depressive symptoms, cognitive function, marital status, etc.) affect self-perceived function in both groups, but gait speed is the greatest single predictor of self-perceived function. In nursing home residents depressive symptomatology is related to self-perceived.
Activities of Daily Living↗
Do surgical brain lesions present as isolated dementia? A population-based study.
OBJECTIVE: To determine the incidence of clinically important subdural hematoma (SDH), hydrocephalus not associated with a recent intracranial bleed, and intracranial tumor that is not obviously metastatic, and to test the sensitivity of a promising decision rule for computerized tomography (CT) in dementia. DESIGN: Population-based, retrospective, sequential case series. SETTING: Staff model health maintenance organization (HMO). PATIENTS: Patients aged 65 years and older with one of the three lesions, diagnosed over a 4.5-year period, identified mainly through computerized databases of hospital discharge diagnoses and a registry of malignant tumors. MEASUREMENTS: Clinical data were based on chart review. The decision rule, based on one that had been previously proposed and tested, stated that CT would be required if any one of 11 clinical criteria were met by a patient with cognitive impairment. Rule sensitivity was evaluated using clinical information recorded before CT. MAIN RESULTS: One hundred forty-five clinically important lesions were identified among 137,100 person-years at risk. Average annual incidence per 100,000 was 46.7 (95% CI 36.0, 59.6) for SDH, 5.8 (95% CI 2.5, 11.5) for hydrocephalus not associated with a recent intracranial bleed, and 53.2 (95% CI 41.7, 66.9) for intracranial tumors that were not obviously metastatic. Using the 65 to 74- year age strata as a reference, the relative risk for SDH was 4.8 (95% CI 2.7, 8.5) in 75 to 84-year-olds and 13.1 (95% CI 7.7, 22.5) in the 85 and older strata. Among 59 patients who presented with cognitive impairment, without altered sensorium or physical evidence of trauma, decision rule sensitivity was 93.2% (95% CI 83.5%, 98.1%). Sensitivity was 90.7% (95% CI 77.9%, 97.4%) in the subgroup that presented to an ambulatory care clinic rather than to an emergency department. CONCLUSIONS: These three lesions, which are the most common surgical lesions that may present as dementia, are rare. Most cases have presentations that easily distinguish them from typical Alzheimer's disease. This case series indicates that it may be feasible to develop a decision rule for the selective use of CT in dementia. Disease spectrum will influence measures of decision rule performance such as sensitivity and specificity.
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Isokinetic testing of ankle strength in older adults: assessment of inter-rater reliability and stability of strength over six months.
The study purposes were (1) to estimate the inter-rater reliability of isokinetic strength tests at the ankle in older adults (test-retest interval of three to 7 days), and to determine whether more experienced examiners were more reliable; and (2) to estimate 6 month stability of strength tests. Inter-rater reliability was high for plantar flexion and dorsiflexion tests where average strength was more than about 10 Newton-meters (Nm) (Pearson R = 0.87-0.95). When average strength was less than 10Nm, reliability was less (R = 0.42-0.75). Experienced examiners (physical therapists) and less experienced examiners (research assistants) were equally reliable. Variability in strength over 6 months was no greater than variability over a few days. We conclude that isokinetic tests of ankle strength in older adults are highly reliable and stable when examiners are adequately trained and subjects maintain usual physical activity levels.
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Motor vehicle collision injuries and sensory impairments of older drivers.
To determine whether ocular disease, impaired vision, or diminished hearing might increase the risk of motor vehicle collision injuries in older drivers, we conducted a population-based case-control study at a large Health Maintenance Organization (HMO). All study subjects were HMO members who were licensed drivers age 65 or over. Cases were drivers treated for injuries sustained in a police-reported collision that occurred in 1987 or 1988. Controls were drivers who experienced no such injury during the study years and were matched to cases by age, sex, and county of residence. We found no clear evidence that ocular diseases or impaired visual acuity, as customarily recorded in the medical record, increased the risk of an injury collision. Although there was no significant association between impaired hearing and injury collision, we found that subjects who used hearing aids while driving had about twice the risk of others (adjusted RR 2.1; 95% CI 1.2-3.8). We conclude that mild reductions in static visual acuity have little effect on the risk of injury collisions for older drivers. Moreover, the types of vision tests needed to identify elderly drivers at increased risk are not those that are generally administered during routine optometry examinations or at the time of licence renewal. Further research is needed to verify a possible increase in risk among elderly drivers using hearing aids.
Accidents, Traffic↗
Inpatient geriatric evaluation and management units (GEMs) in the veterans health system: diamonds in the rough?
BACKGROUND: Research suggests that inpatient geriatric evaluation and management units (GEMs), which undertake interdisciplinary diagnosis to improve the health of frail elderly patients, are effective. The Department of Veterans Affairs (VA) helped pioneer U.S. GEMs and mandates that every facility shall have a GEM by 1996. We conducted a population survey of VA GEMs in 1991 to assess their dissemination. METHODS: Various organizational and performance characteristics of GEMs were entered in a data base derived from a piloted questionnaire and administrative records. Basic criteria from consensus reports were used to classify and compare "standard" and "nonstandard" GEMs. The criteria covered performance of assessment, team structure, patient selection, GEM location, and treatment functions. We analyzed the effect of GEM type and other factors on length of stay and placement. Reasons for closure of GEMs inactive in 1991 were recovered, and GEMs active in 1991 but later closed are described. RESULTS: As of 1991, 41 of 73 GEMs were classified as standard, and 32 nonstandard. Standard compared to nonstandard GEMs had shorter stays (25.4 vs 69.9 days; p < .001), higher home discharge rates (63.4% vs 40%; p < .001), and lower nursing home placement rates (19.1% vs 40.3%; p < .001). Eleven hospitals had closed their programs by 1991. By 1993, 6 additional GEMs had closed; all were nonstandard in 1991. CONCLUSIONS: Most VA GEMs are organized according to basic consensus standards, and appear to be discharging most patients back to the community after reasonably short stays. However, various resource constraints are common, apparently reflected in nonstandard organization and GEM closure. Additional work is needed to monitor GEM proliferation, implementation, and performance in and out of the VA system.
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Inpatient geriatric evaluation and management units: organization and care patterns in the Department of Veterans Affairs.
Geriatric evaluation and management units (GEMs) are designed to improve the functional health and placement of frail elderly hospital inpatients. We surveyed Department of Veterans Affairs (VA) GEMs to describe their care patterns and organization. GEMs meeting consensus standards (n = 46) varied considerably. Hospital, GEM, and patient-admission factors (e.g., hospital psychiatric mix, GEM location, proportion of GEM admissions from nursing homes) predicted length-of-stay, readmission rate, and discharge status. Ongoing monitoring may improve the effectiveness of VA GEMs systemwide.
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Psychoactive medications and injurious motor vehicle collisions involving older drivers.
Older drivers have the second highest risk for motor vehicle collisions of any age group, after adolescents. Psychoactive medications may place older drivers at increased risk for injurious motor vehicle collisions. We conducted a population-based matched case-control study of older drivers who were involved in injurious crashes during 1987 and 1988. The 234 cases and 447 controls were members of a large Seattle-based health maintenance organization. Use of anti-depressants and opioid analgesics by older drivers was associated with increased risk for injurious motor vehicle collisions. Compared with non-users, current users of cyclic antidepressants had an adjusted relative risk (RR) of 2.3 [95% confidence interval (CI) = 1.1-4.8]. Opioid analgesic use was also associated with an elevated crash risk (adjusted RR = 1.8; 95% CI = 1.0-3.4). We found no evidence of a dose-related effect with either class of drug. Current use of benzodiazepines or sedating antihistamines had little association with increased risk for injurious collisions.
Accidents, Traffic↗
Medical conditions and motor vehicle collision injuries in older adults.
OBJECTIVE: To determine whether medical conditions that can impair sensory, cognitive, or motor function increase the risk of injury due to motor vehicle collision in older drivers. DESIGN: Case-control study. SETTING: Group Health Cooperative of Puget Sound, a large prepaid health plan. PARTICIPANTS: Group Health members age 65 or older who were licensed drivers in 5 counties. Cases were injured while driving during 1987 or 1988. Controls were matched to cases on age, gender, and county of residence but experienced no such injury during the study years. MEASUREMENTS: The outcome was injury requiring medical care due to a police-investigated motor vehicle collision. Risk factors evaluated included selected medical conditions active within the previous 3 years, as determined from the medical record. MAIN RESULTS: Injury risk was 2.6-fold higher in older diabetic drivers (95% CI: 1.4-4.7), especially those treated with insulin (odds ratio [OR] = 5.8, 95% CI: 1.2-28.7) or oral hypoglycemic agents (OR = 3.1, 95% CI: 0.9-11.0), those with diabetes for over 5 years (OR = 3.9, 95% CI: 1.7-8.7), and those with both diabetes and coronary heart disease (OR = 8.0, 95% CI: 1.7-37.7). Increases were also found for older drivers with coronary artery disease (OR = 1.4), depression (OR = 1.7), alcohol abuse (OR = 2.1), or falls (OR = 1.4), but these associations could easily have arisen by chance. CONCLUSIONS: Counseling about driving risks may be warranted for certain elderly diabetic drivers. Further research is needed to determine whether transient hypoglycemia or long-term complications explain these effects.
Accidents, Traffic↗
Preventing disability and falls in older adults: a population-based randomized trial.
OBJECTIVES: Because preventing disability and falls in older adults is a national priority, a randomized controlled trial was conducted to test a multicomponent intervention program. METHODS: From a random sample of health maintenance organization (HMO) enrollees 65 years and older, 1559 ambulatory seniors were randomized to one of three groups: a nurse assessment visit and follow-up interventions targeting risk factors for disability and falls (group 1, n = 635); a general health promotion nurse visit (group 2, n = 317); and usual care (group 3, n = 607). Data collection consisted of a baseline and two annual follow-up surveys. RESULTS: After 1 year, group 1 subjects reported a significantly lower incidence of declining functional status and a significantly lower incidence of falls than group 3 subjects. Group 2 subjects had intermediate levels of most outcomes. After 2 years of follow-up, the differences narrowed. CONCLUSIONS: The results suggest that a modest, one-time prevention program appeared to confer short-term health benefits on ambulatory HMO enrollees, although benefits diminished by the second year of follow-up. The mechanisms by which the intervention may have improved outcomes require further investigation.
Accidental Falls↗
Development of the common data base for the FICSIT trials.
The eight FICSIT (Frailty and Injuries: Cooperative Studies of Intervention Techniques) sites test different intervention strategies in selected target groups of older adults. To compare the relative potential of these interventions to reduce frailty and fall-related injuries, all sites share certain descriptive (risk-adjustment) measures and outcome measures. This article describes the shared measures, which are referred to as the FICSIT Common Data Base (CDB). The description is divided into four sections according to the four FICSIT committees responsible for the CDB: (1) psychosocial health and demographic measures; (2) physical health measures; (3) fall-related measures; and (4) cost and cost-effectiveness measures. Because the structure of the FICSIT trial is unusual, the CDB should expedite secondary analyses of various research questions dealing with frailty and falls.
Accidental Falls↗
The Seattle FICSIT/MoveIt study: the effect of exercise on gait and balance in older adults.
While exercise is generally recommended for older adults, the specific role of exercise in preventing falls and frail health is unclear. The Seattle FICSIT/MoveIt study is a population-based, randomized, controlled trial comparing the effects of three 6-month exercise interventions (endurance training, strength training, or combined endurance and strength training), and three 3-month endurance training interventions (stationary cycle, walking, or aerobic movement). Primary study outcomes are aerobic capacity, strength, gait, balance, and physical functional status. The study enrolls adults age 68-85 who have leg weakness and impaired gait. It differs from most previous community-based exercise studies in several respects: recruitment of subjects from a defined population; eligibility criteria based upon physiologic and functional status deficits; random assignment to exercise groups; assessment of both physiologic and functional status outcomes; follow-up beyond the completion of supervised exercise; and a large sample size (Total N = 180).
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