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Biomedical subjects

Thomas M Gill

Publications and source records attributed to Thomas M Gill.

At least 19 recordsLinked to original sources
PubMed2006

Improved self-confidence was a mechanism of action in two geriatric trials evaluating physical interventions.

OBJECTIVE: To evaluate the mechanisms of action in two successful geriatric clinical trials that tested multicomponent physical conditioning programs and to determine whether the pathways for overall benefit were through improvement in physical ability and/or self-confidence. STUDY DESIGN AND SETTING: PREHAB and DRIVER were conducted by the Yale Pepper Center. PREHAB participants received an individualized program that focused on the impairments present (standardly tailored design); DRIVER participants received the entire intervention (global design). PREHAB enrolled 188 community-living persons, aged 75 years or older, who were physically frail but ambulatory; DRIVER enrolled 178 drivers aged 70 years or older with physical impairments associated with poor driving performance. The primary outcome for PREHAB was a disability score and for DRIVER it was a driving score; potential mediators were measures of physical ability and self-confidence. RESULTS: In PREHAB, pathways for the intervention were established through improvement in physical ability and self-confidence. In DRIVER, there was some evidence for a pathway through improved driving self-confidence but not through physical ability; however, the intervention effect was largely unexplained. CONCLUSION: Multicomponent physical interventions may operate through psychological mechanisms, and these mechanisms should be anticipated in trial designs so that the component effects can be suitably evaluated.

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PubMed2006

Transitions between frailty states among community-living older persons.

BACKGROUND: Little is known about the natural course of frailty. We performed a prospective study to determine the transition rates between frailty states and to evaluate the effect of the preceding frailty state on subsequent frailty transitions. METHODS: We studied 754 community-living persons, aged 70 years or older, who were nondisabled in 4 essential activities of daily living. Frailty, assessed every 18 months for 54 months, was defined on the basis of weight loss, exhaustion, low physical activity, muscle weakness, and slow walking speed. Participants were classified as frail if they met 3 or more of these criteria, as prefrail if they met 1 or 2 of the criteria, and as nonfrail if they met none of the criteria. RESULTS: Of the 754 participants, 434 (57.6%) had at least 1 transition between any 2 of the 3 frailty states during 54 months. The rates were 36.8%, 21.5%, and 9.2% for 1, 2, and 3 transitions, respectively. During the 18-month intervals, transitions to states of greater frailty were more common (rates up to 43.3%) than transitions to states of lesser frailty (rates up to 23.0%), and the probability of transitioning from being frail to nonfrail was very low (rates, 0%-0.9%), even during an extended period. The likelihood of transitioning between frailty states was highly dependent on one's preceding frailty state. CONCLUSIONS: Frailty among older persons is a dynamic process, characterized by frequent transitions between frailty states over time. Our findings suggest ample opportunity for the prevention and remediation of frailty.

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PubMed2006

Effects of a physical activity intervention on measures of physical performance: Results of the lifestyle interventions and independence for Elders Pilot (LIFE-P) study.

BACKGROUND: The Short Physical Performance Battery (SPPB), which includes walking, balance, and chair stands tests, independently predicts mobility disability and activities of daily living disability. To date, however, there is no definitive evidence from randomized controlled trials that SPPB scores can be improved. Our objective was to assess the effect of a comprehensive physical activity (PA) intervention on the SPPB and other physical performance measures. METHODS: A total of 424 sedentary persons at risk for disability (ages 70-89 years) were randomized to a moderate-intensity PA intervention or a successful aging (SA) health education intervention and were followed for an average of 1.2 years. RESULTS: The mean baseline SPPB score on a scale of 0-12, with 12 corresponding to highest performance, was 7.5. At 6 and 12 months, the PA versus SA group adjusted SPPB (+/- standard error) scores were 8.7 +/- 0.1 versus 8.0 +/- 0.1, and 8.5 +/- 0.1 versus 7.9 +/- 0.2, respectively (p < .001). The 400-meter walking speed was also significantly improved in the PA group. The PA group had a lower incidence of major mobility disability defined as incapacity to complete a 400-meter walk (hazard ratio = 0.71, 95% confidence interval = 0.44-1.20). CONCLUSIONS: A structured PA intervention improved the SPPB score and other measures of physical performance. An intervention that improves the SPPB performance may also offer benefit on more distal health outcomes, such as mobility disability.

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PubMed2006

The effect of prior disability history on subsequent functional transitions.

BACKGROUND: Many older persons experience multiple transitions between states of disability and independence, but little is known about the effect of prior disability history on subsequent functional transitions. Our objective was to determine the effect of prior disability on subsequent transitions between no disability, mild disability, severe disability, and death. METHODS: For 60 months, 754 persons aged 70 or older underwent monthly assessments of disability in basic activities of daily living. We used a multistate extension of the proportional hazards model to determine the effects of amount, defined as cumulative duration, and distribution, defined as number of episodes, of prior disability on subsequent functional transitions, adjusted for age, gender, cognitive status, timed gait, and habitual physical activity. RESULTS: For each additional month of prior disability, participants were more likely to make transitions representing new or worsening disability and were less likely to make transitions from disability to independence or from severe disability to death. Adjusting for the cumulative duration of prior disability, more episodes of prior disability were associated with a higher likelihood of most transitions, representing both increasing and decreasing disability, but had no effect on transitions to death. CONCLUSIONS: Both the amount and distribution of prior disability are important determinants of the likelihood of subsequent functional transitions. Analytic methods that account for prior disability history should be used in studies of functional transitions, and new measures of disability burden are needed that incorporate distribution as well as amount of disability.

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PubMed2006

Bathing disability and the risk of long-term admission to a nursing home.

BACKGROUND: The prevalence of disability in bathing and the likelihood of a long-term nursing home admission increase substantially with age. We performed a prospective study to determine whether the occurrence of persistent disability in bathing is associated with the risk of a long-term nursing home admission, independent of potential confounders, including persistent disability in other essential activities of daily living. METHODS: We studied 754 community-living persons, 70 years old or older, who were nondisabled in four essential activities of daily living. Participants were followed with monthly telephone interviews for a median of 75 months to determine the occurrence of persistent (i.e., present for at least 2 consecutive months) disability in bathing and the time to the first long-term nursing home admission, defined as longer than 3 months. RESULTS: One hundred thirteen (15.0%) participants had a long-term nursing home admission. At least one episode of persistent bathing disability occurred among 59 (52.2%) participants with a long-term nursing home admission and 210 (32.8%) without a long-term admission (p <.001). In a proportional hazards model that was fully adjusted for potential confounders, the occurrence of persistent bathing disability increased the risk of a long-term nursing home admission by 77% (hazard ratio 1.77, 95% confidence interval 1.05 to 2.98), but had no effect on the risk of a short-term nursing home admission (hazard ratio 0.87, 95% confidence interval 0.51 to 1.49). CONCLUSIONS: Among community-living older persons, the occurrence of persistent disability in bathing is independently associated with the risk of a long-term nursing home admission, but has no effect on short-term admissions. Interventions directed at the prevention and remediation of bathing disability have the potential to reduce the burden and expense of long-term care services.

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PubMed2006

Hearing decline predicted by elders' stereotypes.

Although age-related hearing loss is one of the most prevalent conditions affecting older individuals, little research has been conducted on the social-psychological factors that might contribute to it. The present study examines whether older individuals' age stereotypes predict screened hearing over time. The sample consisted of 546 community-dwelling persons, aged 70 to 96 years old. Participants with more negative and more external (i.e., related to physical appearance) age stereotypes demonstrated worse screened hearing at 36 months, after adjusting for baseline-screened hearing, age, and other relevant variables. These findings suggest that age stereotypes influence older individuals' sensory perception.

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PubMed2006

The dynamic nature of mobility disability in older persons.

OBJECTIVES: To determine the rates of clinically meaningful transitions in mobility disability; evaluate how these transitions differ according to age, sex, and physical frailty; and depict the duration of the resulting episodes of mobility disability. DESIGN: Prospective cohort study. SETTING: General community in greater New Haven, Connecticut, from March 1998 to October 2004. PARTICIPANTS: Seven hundred fifty-four community-living older persons, aged 70 and older, who were nondisabled (i.e., required no personal assistance) in four activities of daily living. MEASUREMENTS: Mobility disability, defined as the inability to walk one quarter of a mile and to climb a flight of stairs, respectively without personal assistance, was assessed every month for up to 5 years. RESULTS: For both mobility tasks, rates per 1,000 person-months were higher for transitions from no disability to intermittent disability (34.7 for walking one quarter of a mile and 17.4 for climbing a flight of stairs), intermittent to continuous disability (52.0 and 42.5), continuous to intermittent disability (35.4 and 31.5), and intermittent to no disability (68.6 and 85.4) than for other transitions. Older age, female sex, and physical frailty were associated with greater likelihood of transition to states of greater disability and lower likelihood of regaining independent mobility. CONCLUSION: Mobility disability in older persons is a highly dynamic process, characterized by frequent transitions between states of independence and disability. Programs designed to enhance independent mobility should focus not only on the prevention of mobility disability but also on the restoration and maintenance of independent mobility in older persons who become disabled.

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PubMed2006

The epidemiology of bathing disability in older persons.

OBJECTIVES: To quantify the burden of bathing disability over time; to determine whether the burden of bathing disability differs according to age, sex, and physical frailty; and to evaluate the relationship between disability in bathing and disability in other essential activities of daily living (ADLs). DESIGN: Prospective cohort study. SETTING: General community in greater New Haven, Connecticut. PARTICIPANTS: Seven hundred fifty-four community-living older persons aged 70 and older who were nondisabled (required no personal assistance) in four essential ADLs: bathing, dressing, transferring from a chair, and walking inside the house. MEASUREMENTS: Bathing disability, defined as the inability to wash and dry one's whole body without personal assistance, was assessed every month for up to 6 years, along with disability in dressing, transferring, and walking. RESULTS: Over the course of 6 years, 440 participants (58.4%) had at least one episode of bathing disability, and 266 (34.0%) had multiple episodes, with the duration of each episode averaging about 6 months. Whether assessed as number of episodes, duration of episodes, incidence rates, or number of months per 100 months, the burden of bathing disability was greatest in participants who were physically frail and was consistently higher in women than men and in participants who were aged 80 and older than those who were aged 70 to 79. Most episodes of bathing disability (86.1%) were not preceded in the prior month by disability in dressing, transferring, or walking, and nearly half (48.3%) were not accompanied at onset by disability in one or more of these other ADLs. In a multivariable model that included age, sex, and physical frailty, the onset of bathing disability increased the likelihood of developing disability in the other essential ADLs the following month fivefold (hazard ratio=5.1, 95% confidence interval=4.1-6.4). CONCLUSION: Disability in bathing may serve as a sentinel event in the disabling process. Given the recurrent nature of bathing disability, programs designed to enhance independent bathing will need to focus not only on the prevention of bathing disability, but also on the restoration and maintenance of independent bathing in older persons who become disabled.

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PubMed2006

Longitudinal change in positive affect in community-dwelling older persons.

OBJECTIVES: To determine whether positive affect, defined as emotional contentment and happiness, remains stable in late life and to identify predictors of longitudinal change in positive affect. DESIGN: Longitudinal observational study. SETTING: Community. PARTICIPANTS: Six hundred sixty-three individuals aged 70 and older without disability at baseline and free of chronically depressed mood. MEASUREMENTS: Positive affect, social network, social activity, chronic health conditions, activities of daily living, instrumental activities of daily living (IADLs), cognitive functioning, and negative affect measured over 54 months, at 18-month intervals, up to four times. RESULTS: Positive affect remained relatively stable over 4.5 years of follow-up. Higher average levels of social activity and lower levels of negative affect were associated with higher positive affect. An increase of 1 point in negative affect (on a 7-point scale) was associated with a 0.23-point concurrent decrease in positive affect (on a 5-point scale). Needing help in an additional IADL was associated with a decrease in positive affect of 0.04 points. A greater number of chronic conditions at enrollment was associated with lower positive affect. CONCLUSION: Positive affect is directly correlated with social involvement and inversely correlated with negative affect, IADL functioning, and comorbidity. Positive affect was mostly related to factors that do not change over time, although it showed some sensitivity to short- and long-term changes in physical health and functioning.

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PubMed2005

Transitions between states of disability and independence among older persons.

The objectives of this prospective cohort study, conducted in New Haven, Connecticut, from 1998 to 2004, were to describe disability states experienced by older persons, to evaluate the rate of transitions between states and the duration of disability episodes, and to determine whether these findings differ on the basis of physical frailty--a condition of low physical capacity and vulnerability to adverse functional outcomes. Participants included 754 persons aged 70 years or older who were initially independent in four key activities of daily living: bathing, dressing, walking, or transferring. Disability was assessed during monthly telephone interviews for a median of 60 months, and participants were classified each month according to the following four states: no disability, mild disability (one or two activities), severe disability (three or four activities), and death. Transitions between states of disability and independence were common, with a majority of both frail and nonfrail participants experiencing at least one transition. The rate of transitions varied greatly among individuals. Nonfrail participants had lower rates of transition from less to more disability, higher rates of transition from more to less disability, and slightly shorter durations of disability. To fully understand the disabling process, investigators and clinicians must consider the episodic and recurrent nature of disability.

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PubMed2005

Decline in physical performance among women with a recent transient ischemic attack or ischemic stroke: opportunities for functional preservation a report of the Women's Estrogen Stroke Trial.

BACKGROUND AND PURPOSE: Physical performance for walking, reaching, turning, and other common tasks is a major determinant of functional independence after stroke. Current strategies to preserve physical performance focus on prevention of recurrent stroke. Loss of physical performance, however, may occur in the absence of recurrence. To examine this possibility, we measured change in physical performance, independent of subsequent stroke, among women with a recent ischemic stroke or transient ischemic attack (TIA). METHODS: Among 664 postmenopausal women who participated in a clinical trial of estrogen therapy after stroke or TIA, we administered the Physical Performance Test (PPT) at baseline (mean 58 days from the cerebrovascular event) and annually. Women who died or had a stroke during follow-up were censored. Decline or improvement in physical performance was defined as a change in the PPT score from baseline of at least 3 points. Sustained decline or improvement was defined as 2 consecutive years during which the score had declined or improved, respectively, relative to the baseline score. RESULTS: With each year of follow-up, a smaller proportion of the cohort demonstrated improvement (16% in year 1, 6% in year 5) and a larger proportion demonstrated decline (15% in year 1, 35% in year 5). In an analysis restricted to 259 women with 3 years of follow-up, 46 (18%) experienced a nonsustained decline in physical performance, and 39 (15%) experienced a sustained decline. CONCLUSIONS: Decline in physical performance is common after an ischemic stroke or TIA even in the absence of a recurrent neurological event. Our findings suggest that specific interventions to maintain and improve physical performance may be important for reducing long-term disability.

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PubMed2005

Factors associated with recovery of independence among newly disabled older persons.

BACKGROUND: Recent evidence indicates that most older persons who develop disability in their activities of daily living (ADLs) regain independent function, but many of these persons subsequently experience recurrent disability. The aims of this study were to identify independent predictors of time to and duration of recovery of independent ADL function among newly disabled community-dwelling older persons. METHODS: From a cohort of 754 persons 70 years or older, we studied the 420 participants who experienced at least 1 episode of disability involving 1 or more key ADLs (bathing, dressing, walking, or transferring) during a median follow-up of 53 months. Comprehensive evaluations at baseline and every 18 months included demographic, medical, cognitive, psychological, social, behavioral, and physical factors. Activities of daily living function and hospital admissions were assessed during monthly telephone interviews, with a completion rate of 99.4%. RESULTS: Of the 420 newly disabled participants, 342 (81.4%) recovered independent ADL function after a mean +/- SD of 4.9 +/- 0.5 months. In multivariable proportional hazards analysis, habitual physical activity, mild disability (1-2 ADLs) at onset, and hospitalization in the month of disability onset were independently associated with shorter time to recovery. Among participants who recovered, 251 (73.4%) experienced recurrent disability or death after a mean +/- SD of 7.3 +/- 8.5 months. Younger age, greater habitual physical activity, higher functional self-efficacy, and shorter duration of the prior disability episode were independently associated with longer duration of recovery. CONCLUSIONS: Habitual physical activity is an independent predictor of time to and duration of recovery of independent ADL function among newly disabled community-dwelling older persons. Because the other independent predictors for time to recovery differ from those for maintenance of recovery, different mechanisms may underlie these 2 recovery outcomes, suggesting that different interventions may be required to promote recovery than to maintain independent ADL function after recovery.

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PubMed2005

The lifestyle interventions and independence for elders (LIFE) pilot study: design and methods.

The LIFE study is a multicenter pilot for a proposed full scale, two-arm randomized controlled trial that will contrast the effect of a physical activity intervention with a successful aging education program on the occurrence of incident major mobility disability (the inability to complete a 400 m walk) or death in at-risk sedentary older adults. Four hundred older adults from 4 clinical sites will be recruited for this purpose. All participants will be followed for at least 1-year; however, we will continue to follow all participants until the final randomized individual has reached the 1-year mark. This will enable us to acquire additional information about maintenance. Additional outcomes will include lower extremity physical performance as well as gait speed over 4 m and 400 m. These latter measures will provide data on the efficacy of the intervention on intermediate endpoints linked to the primary outcome of interest. The goals of the pilot study are to (a) estimate the sample size needed for a full scale trial, (b) examine the consistency of the effects of the physical activity intervention on several continuous measures of physical function, (c) assess the feasibility of recruitment, (d) evaluate study adherence and retention, (d) evaluate the efficacy of a stepped care approach for managing intercurrent illness in this at-risk population, and (e) develop a comprehensive system for monitoring and ensuring participant safety. Other goals of this pilot phase include assessments of health-related quality of life and cost-effectiveness.

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PubMed2005

Health behaviors associated with better quality of life for older bereaved persons.

BACKGROUND: Bereavement is a risk factor for declines in health, adverse health behaviors, increased physician visits, and mortality, and occurs with greatest frequency in later life. Little is known about health behaviors that are associated with better quality of life among recently bereaved older persons. OBJECTIVE: The objective of this community-based longitudinal, observational study was to examine the influence of health behaviors on the quality of life of 200 elderly bereaved persons. DESIGN AND MEASUREMENTS: Health behaviors (i.e., exercise, monitoring caloric intake, sleep, daily vitamin intake, annual health check-ups) were examined at approximately 6 months postloss (baseline) and 11 months postloss (Wave 2). Quality of life was assessed at approximately 11 months postloss and 19 months postloss (Wave 3), using the RAND 36-Item Health Survey, which measures 8 domains of health and functioning, plus a single item assessing change in health. RESULTS: Consistently exercising 1 or more days per week at Waves 1 and 2 significantly (p < .05) predicted better self-rated health, physical functioning, fewer physical role limitations, and greater energy at Wave 3 in models that adjusted for age, gender, prior psychiatric disorder, baseline reports of functional disabilities and chronic conditions. Consistently monitoring caloric intake at Waves 1 and 2 predicted better self-rated health (p < .05), greater energy (p < .01), and positive change in health (p < .05) at Wave 3 in models that adjusted for the above set of control variables. Sleeping 6.5-9 hours per night at baseline alone predicted better social functioning (p < .001), fewer emotional role limitations (p < .01), better emotional health (p < .001), and greater energy (p < .01). CONCLUSIONS: Should future research confirm these results, clinicians would be advised to recommend the identified preventive and protective health behaviors to recently bereaved older patients.

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PubMed2005

Identification of pain-reduction strategies used by community-dwelling older persons.

BACKGROUND: The types of methods used by older persons to reduce chronic pain have not been adequately characterized. In this cross-sectional study of older persons with chronic nonmalignant pain, we sought to identify strategies perceived as effective in reducing pain and to ascertain factors associated with their use. METHODS: Participants included 272 community-dwelling persons aged 73 years or older. Information regarding participants' sociodemographic, clinical, psychological, and pain status was collected. Strategies perceived as effective in reducing pain were identified using a qualitative approach. Similar methods (e.g., "takes acetaminophen when necessary" and "uses Tramadol daily") were grouped into specific pain-reduction categories (e.g., analgesic medication use). Logistic regression analysis was used to identify associations between participant-related factors and the four most prevalent pain-reduction strategies. RESULTS: Participants had a mean (standard deviation) age of 80.9 (5.1) years and were mostly female (69%). Overall, 248 (91%) participants reported at least one effective strategy for reducing pain; the mean number of strategies per participant was 2.7 (range = 1-6). The four most prevalent pain-reduction strategies were analgesic medication use (reported by 59% of participants), activity restriction (38%), hot and/or cold modalities (28%), and exercise (23%). Although most participants reported at least one effective pain-reduction strategy, 60% rated their pain as "quite a bit" or "extremely" bothersome. In logistic regression analysis, no factor (including age and gender) was independently associated with any of the prevalent pain-reduction strategies. CONCLUSIONS: Despite the fact that most participants perceived several pain-reduction strategies as effective, 60% reported experiencing substantial pain. Research of older persons with chronic pain is warranted to determine whether changes in the way existing pain-reduction strategies are administered can improve the management of pain or if more efficacious strategies are needed.

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PubMed2005

Back pain and decline in lower extremity physical function among community-dwelling older persons.

BACKGROUND: Little is known regarding the longitudinal effects of back pain on physical function among older persons. We sought to determine whether back pain leading to activity restriction (i.e., restricting back pain) is associated with decline in lower extremity physical function among community-dwelling older persons. METHODS: In this prospective study with an 18-month follow-up period, participants (N = 659) were aged 70 years or older and independent in bathing, dressing, transferring, and walking at baseline. Restricting back pain, defined as staying in bed for at least one-half day or cutting down on one's usual activities due to back pain, was ascertained during monthly telephone interviews. Lower extremity physical function was assessed using three timed, performance-based tests (rapid gait, chair stands, and foot taps) at baseline and 18 months. Decline in lower extremity physical function was defined as an increase in timed scores on these tests between the baseline and 18-month assessments. RESULTS: The mean (standard deviation) number of months with restricting back pain was 1.3 (2.3); 364 (55%) participants reported 0 months, 209 (32%) reported 1-3 months, and 86 (13%) reported 4 or more months. After adjustment for baseline performance score and other covariates, the number of months with restricting back pain was independently associated with worsening rapid gait (p <.001), chair stand (p =.030), and foot tap (p <.001) performance. The deleterious effects of the "exposure" were limited to participants with 4 months of restricting back pain. CONCLUSIONS: Restricting back pain is independently associated with decline in lower extremity physical function among community-dwelling older persons. Treatment of restricting back pain may help to decrease functional decline in this population.

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PubMed2005

Estimates of active and disabled life expectancy based on different assessment intervals.

BACKGROUND: Although disability in activities of daily living (ADLs) is a highly dynamic process, analytic strategies for estimating active and disabled life expectancy have assumed stability in ADL function between periodic surveys spanning 12--24 months or have used interval estimation or instantaneous rates based on long assessment intervals. We performed a prospective cohort study to compare estimates of active and disabled life expectancy based on traditional assessment intervals of 1--2 years with those based on more frequent assessments at 1-month intervals. METHODS: Participants included 754 initially nondisabled community-dwelling persons, aged 70 years or older, who were interviewed monthly for 4 years to ascertain ADL disability. Estimates of active and disabled life expectancy were calculated using an increment-decrement life table for assessment intervals of 1 month, 1 year, and 2 years. RESULTS: For each of five age groups, the monthly assessment strategy yielded the highest values for active life expectancy and the lowest values for disabled life expectancy. The 95% confidence intervals for these values, however, overlapped the corresponding point estimates for the annual and biennial strategies. CONCLUSIONS: Accurate estimates of active and disabled life expectancy may be obtained from epidemiologic studies that assess ADL function no more frequently than every other year.

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