Jenni Kulmala

Poor vision accompanied with other sensory impairments as a predictor of falls in older women

OBJECTIVES we studied visual acuity (VA) and co-existing hearing impairment and poor standing balance as predictors of falls. DESIGN prospective study with 1-year follow-up. SETTING research laboratory and residential environment. PARTICIPANTS 428 women aged 63-76 years from the Finnish Twin Study on Aging. MEASUREMENTS participants were followed up for incidence of falls over 1 year. VA, hearing ability and standing balance were assessed at the baseline. The incidence rate ratios (IRR) for falls were computed using the negative binomial regression model. RESULTS during the follow-up, 47% of participants experienced a fall. After adjusting for age and interdependence of twin sisters, participants with vision impairment (VA of <1.0) but no other sensory impairments had a higher, but non-significant, risk for falls compared to persons with normal vision (IRR 1.5, 95% CI 0.6-4.2). Co-existing vision impairment and impaired balance increased the risk (IRR 2.7, 95% CI 0.9-8.0), as also did co-existing vision and hearing impairment (IRR 4.2, 95% CI 1.5-11.3), compared to those with normal vision. Among persons with all three impairments, the IRR for falls increased to 29.4 (95% CI 5.8-148.3) compared to participants with good vision. CONCLUSION the impact of vision impairment on fall risk was higher when accompanied with other sensory and balance impairments, probably because the presence of other impairments prevented the reception of compensatory information about body posture and environment being received from other sensory sources. When aiming to prevent falls and their consequences in older people, it is important to check whether poor vision is accompanied with other impairments.

Association between Frailty and Dementia: A Population-Based Study

Background: Frailty is commonly considered as a syndrome with several symptoms, including weight loss, exhaustion, weakness, slow walking speed and physical inactivity. It has been suggested that cognitive impairment should be included in the frailty index, however the association between frailty and cognition has not yet been fully established. Objective: To investigate cross-sectionally whether frailty is associated with cognitive impairment or clinically diagnosed dementia in older people. Methods: The study included a total of 654 persons aged 76-100 years (mean 82 ± 4.6). Frailty status of the participants was assessed using the Cardiovascular Health Study criteria. Cognitive function was assessed with the Mini-Mental State Examination (MMSE). Clinically diagnosed dementia was assessed by specialists using diagnostic criteria. The associations between frailty and cognition were investigated using logistic regression. Results: A total of 93 (14%) participants were classified as frail. Cognitive impairment (MMSE score <25) was observed among 171 (26%) persons and 134 (21%) persons had clinically diagnosed dementia. 97 (15%) persons had Alzheimers disease, 19 (3%) had vascular dementia, 12 (2%) had dementia with Lewy bodies and 8 persons (1%) had some other type of dementia. Multivariate logistic regression models showed that frail persons were almost 8 times more likely to have cognitive impairment (OR 7.8, 95% CI 4.0-15.0), 8 times more likely to have some kind of dementia (OR 8.0, 95% CI 4.0-15.9), almost 6 times more likely to have vascular dementia (OR 5.6, 95% CI 1.2-25.8) and over 4 times more likely to have Alzheimers disease (OR 4.5, 95% CI 2.1-9.6) than persons who were robust. Conclusion: Frailty is strongly associated with cognitive impairment and clinically diagnosed dementia among persons aged 76 and older. It is possible that cognitive impairment is a clinical feature of frailty and therefore should be included in the frailty definition.

Lowered vision as a risk factor for injurious accidents in older people

Background and aims: Poor vision in older people is often related to increased fall risk. However, the association of the severity between visual deficit and risk for all kind of injurious accidents has not been widely studied. The aim of this study was to examine whether visual loss is associated with higher incidence of injurious accidents and whether walking speed or physical activity play a mediating role in the association. Methods: 416 persons aged 75 and 80 years at baseline underwent visual acuity measurements. Visual acuity (VA) <0.3 in the better eye, with spectacle correction when necessary, was defined as visual impairment, VA ≥0.3 but ≤0.5 as lowered vision, and VA>0.5 as normal VA. Hospital records of accidents resulting in injury were monitored for 10 years after baseline. Results: During the 10-year follow-up, 239 (58%) participants suffered at least one injurious accident. The risk for injurious accidents in a multivariate model adjusted for age, gender, eye-related diseases, diabetes and cardiovascular diseases among participants with lowered vision was 1.45 (95% CI 1.08−1.94), compared with that for people with normal visual acuity. Participants with visual impairment did not have an increased risk for injurious accidents (HR 1.20, 95% CI 0.82−1.75). Furthermore, neither walking speed nor physical activity had a mediating effect on the relationship between visual loss and accidents. Conclusions: Lowered vision is a risk factor for injurious accidents in older people independent of mobility and physical activity. Interestingly, more severe visual impairment did not increase the risk. Early intervention strategies, for example, proper correction of refractive errors or cataract extraction, may potentially prevent injurious accidents in older people.

Fear of Falling and Coexisting Sensory Difficulties As Predictors of Mobility Decline in Older Women

BACKGROUND Mobility decline, the coexistence of several sensory difficulties and fear of falling (FOF) are all common concerns in older people; however, knowledge about the combined effect of FOF and coexisting sensory difficulties on mobility is lacking. METHODS Data on self-reported FOF, difficulties in hearing, vision, balance, and walking 2 km were gathered with a structured questionnaire among 434 women aged 63-76 years at baseline and after a 3-year follow-up. Logistic regression models were used for analyses. RESULTS Every third participant reported difficulties in walking 2 km at baseline. In cross-sectional analysis, the odds ratio for difficulties in walking 2 km was higher among persons who reported FOF compared with persons without FOF and the odds increased with the increasing number of sensory difficulties. Persons who reported FOF and who had three sensory difficulties had almost fivefold odds (odds ratio = 4.7, 95% confidence interval = 1.9-11.7) for walking difficulties compared with those who reported no FOF and no sensory difficulties. Among the 290 women without walking difficulties at baseline, 54 participants developed difficulty in walking 2 km during the 3-year follow-up. Odds ratio for incident walking difficulty was 3.5 (95% confidence interval = 1.6-7.8) in participants with FOF and with 2-3 sensory difficulties compared with persons without FOF and with at most one sensory difficulty at baseline. CONCLUSIONS Older women who have several coexisting sensory difficulties combined with FOF are particularly vulnerable to mobility decline. Avoidance of walking as a result of FOF is likely to be reinforced when multiple sensory difficulties hinder reception of accurate information about the environment, resulting in accelerated decline in walking ability.

Balance confidence and functional balance in relation to falls in older persons with hip fracture history

Purpose: To investigate whether self‐assessed balance confidence and functional balance are associated with falls in older persons with hip fracture history. Methods: This study is a part of a larger study on functional capacity and exercise rehabilitation in hip fracture patients. Seventy‐nine patients, operated at the local hospital for collum or trochanter fracture within one‐half to 7 years, participated in the laboratory measurements. Balance confidence was assessed with Activities‐specific Balance Confidence scale (ABC) and functional balance using the Berg Balance Scale (BBS). According to self‐reported number of falls during the previous 6 months participants were classified as those with falls vs. no falls; recurrent falls (3 or more falls) vs. occasional/no falls (< 3 falls); indoor falls vs. no indoor falls; outdoor falls vs. no outdoor falls. The relationships between ABC, BBS, and fall status were tested by logistic regression. Results: Lower BBS score was associated with all falls during previous 6 months (OR 0.929, 95% CI 0.875–0.987). Lower ABC score was associated with recurrent falling (OR 0.974, 0.952–0.998), as well as lower BBS score (OR 0.876, 0.797–0.962). Additionally, lower ABC and lower BBS scores were related to indoor falls (ABC OR 0.975, 0.957–0.993; BBS OR 0.913, 0.852–0.978). Participants with outdoor falls did not differ from those with no outdoor falls in ABC scores or BBS. Conclusions: Self‐assessed balance confidence and functional balance are related to prevalence of recurrent and indoor falls in older hip fracture patients. Therefore use of Activities‐specific Balance Confidence scale and Berg Balance Scale might be reasoned to expand in evaluating the probability for falls among at‐risk elders.

Postural Balance and Self-Reported Balance Confidence in Older Adults with a Hip Fracture History

Background: Balance dysfunction and loss of balance confidence have been associated with functional limitations and loss of independency in daily tasks. This study examined various aspects of postural balance and balance confidence between older adults with a hip fracture history and their non-fractured counterparts. A comprehensive assessment of balance capacity in older adults with a hip fracture history may help to identify aspects of postural balance that play an important role in the mobility recovery and the avoidance of further falls. Methods: The present study comprised 79 community-dwelling older adults with a hip fracture history and 31 non-fractured subjects of the same age, who participated in balance tests including both force platform measures and functional balance testing (Berg Balance Scale, BBS). In addition, balance confidence was assessed with the Activities-Specific Balance Confidence (ABC) scale. Results: Persons with a hip fracture history had a markedly poorer balance control and were significantly less confident maintaining their balance during daily activities compared to the controls. Sixty percent of the subjects in the hip fracture group versus 87% of the non-fracture group (χ2 test, p = 0.003) were able to perform the semi-tandem standing with their eyes closed. Significantly lower scores in the BBS (hip fracture group 46.3 vs. non-fracture group 52.9) and ABC (hip fracture group 59.4 vs. non-fracture group 77.5%) tests were found among the hip fracture subjects compared to the controls. In addition, the performance time in the lateral weight-shifting task (hip fracture group 13.4 vs. non-fracture group 8.4 s) was significantly slower compared to the controls. Conclusions: Balance impairments along with the loss of balance confidence are persistent problems among community-dwelling older adults with a history of hip fracture and may contribute to mobility limitations and the risk of falling. These areas of function and behaviour in older adults with a hip fracture history should be taken into consideration when planning effective, well-targeted rehabilitation programs.

Frailty as a predictor of all-cause mortality in older men and women

To investigate the modifying effect of sex on the association between frailty and all‐cause mortality, and to determine the effects of changes in frailty status on mortality.

Perceived Stress Symptoms in Midlife Predict Disability in Old Age: A 28-Year Prospective Cohort Study

BACKGROUND Stress has damaging effects on individuals health. However, information about the long-term consequences of mental stress is scarce. METHODS This 28-year prospective cohort study examined on the associations between midlife stress and old age disability among 2,994 Finnish municipal professionals aged 44-58 years at baseline. Self-reported stress symptoms were assessed at baseline in 1981 and 4 years later in 1985 and perceived disability in 2009. For the baseline data, principal component analysis was used for differentiation into stress symptom profiles. The regression coefficient estimates for self-care disability (activities of daily living) and instrumental activities of daily living disability were estimated using left-censored regression. The odds ratios for mobility limitation were estimated using logistic regression. RESULTS Four midlife stress profiles were identified: negative reactions to work and depressiveness, perceived decrease in cognition, sleep disturbances, and somatic symptoms. We saw a clear gradient of increasing disability severity in old age for increasing intensity of midlife stress symptoms. In comparison with the participants with no stress symptoms, the extensively adjusted left-censored and logistic regression models showed that in old age, disability scores were almost 2-4 units higher and risk for mobility limitation was 2-3 times higher for those with constant stress symptoms in midlife. CONCLUSIONS Among occupationally active 44- to 58-year-old men and women, perceived stress symptoms in midlife correlated with disability 28 years later. Stress symptoms may be the first signs of decompensation of individual functioning relative to environmental demands, which may later manifest in disabilities.

Visual Acuity and Mortality in Older People and Factors on the Pathway

Purpose: To examine vision as a predictor of mortality in older people and the role of mobility, depressed mood, chronic diseases, body mass index, physical activity and injurious accidents in this possible association. Methods: 223 persons aged 75 and 193 persons aged 80 years at the baseline participated in visual acuity measurements. Visual acuity (VA) of < 0.3 in the better eye was defined as visual impairment, VA of ≥ 0.3 but ≤ 0.5 as lowered vision and VA > 0.5 as normal VA. Death dates were received from the official register. Cox regression models were used to determine the relative risks of mortality and to study what factors lie on the pathway from poor vision to mortality. Results: Over the 10-year follow-up, 107 (48%) persons aged 75 years and 138 (72%) aged 80 years at the baseline died. The risk for mortality among the 75-year-olds with lowered vision was 1.98 (95 % CI 1.25–3.13) and with visual impairment 1.90 (95% CI 1.12–3.20) compared to those with normal VA. Lower walking speed, physical inactivity, cardiovascular diseases, injurious accidents, diabetes and depressed mood each attenuated the risk markedly. Nevertheless, lowered vision remained a significant predictor of mortality even after including all these variables in the model. Among the 80-year-olds vision did not correlate with mortality. Conclusions: Lowered vision and severe visual impairment predicted mortality in the 75-year-old but not 80-year-old population. The increased risk was partially explained by lower walking speed, physical inactivity, cardiovascular diseases, depressed mood, diabetes and injurious accidents.

Association between mid- to late life physical fitness and dementia: evidence from the CAIDE study

This study investigated the association between perceived physical fitness at midlife, changes in perceived fitness during the three decades from mid‐ to late life and dementia risk.