Kerstin Frändin

Performance-based physical function in older community-dwelling persons: a systematic review of instruments

BACKGROUND Identification of older persons at risk for the loss of independence, onset of (co)-morbidity or functional limitations through screening/assessment is of interest for the public health-care system. To date several different measurement instruments for overall physical function are frequently used in practice, but little information about their psychometric properties is available. Objectives and METHODS Our aim was to assess instruments with an overall score related to functional status and/or physical performance on content and psychometric properties. Electronic databases (Medline, EMBASE, AMED, Cochrane Library and CINAHL) were searched, using MeSH terms and relevant keywords. Studies, published in English, were included if their primary or secondary purpose was to evaluate the measurement properties of measurement instruments for overall physical function in community-dwelling older persons aged 60 years and older. Reliability, validity, responsiveness and practicability were evaluated, adhering to a specified protocol. RESULTS In total 78 articles describing 12 different functional assessment instruments were included and data extracted. Seven instruments, including their modified versions, were evaluated for reliability. Nine instruments, including their modified versions, were evaluated with regard to validity. CONCLUSION In conclusion, the Short Physical Performance Battery can be recommended most highly in terms of validity, reliability and responsiveness, followed by the Physical Performance Test and Continuous Scale Physical Functional Performance.

Home rehabilitation after hip fracture. A randomized controlled study on balance confidence, physical function and everyday activities:

Objective: To investigate whether home rehabilitation can improve balance confidence, physical function and daily activity level compared to conventional care in the early phase after hip fracture. Design: A randomized controlled study. Setting: Geriatric rehabilitation clinic. Subjects: One hundred and two community-dwelling elderly people. Interventions: A geriatric, multiprofessional home rehabilitation programme focused on supported discharge, independence in daily activities, and enhancing physical activity and confidence in performing daily activities was compared with conventional care in which no structured rehabilitation after discharge was included. Main measures: Falls efficacy, degree of dependency and frequency in daily activities, habitual physical activity and basic functional performance. Results: When comparing status one month after discharge with baseline, the home rehabilitation group showed a higher degree of recovery in self-care (P<0.0001), mobility (P = 0.002), locomotion (P = 0.0036) and domestic activities (P = 0.0098), as well as larger increase in balance confidence on stairs (P = 0.0018) and instrumental activities (mean increase home rehabilitation 19.7 and conventional care 7.1, P<0.0001) compared with the conventional care group. At one month, a majority of the home rehabilitation participants (88%) took outdoor walks, compared with less than half (46%) of the conventional care group (P<0.001) and were also more independent in outdoor activities (P = 0.0014). Conclusions: This study indicates that home rehabilitation, focused on supported discharge and enhancing self-efficacy, improves balance confidence, independence and physical activity in community-dwelling older adults in the early phase after hip fracture.

A Life Span Perspective on Patterns of Physical Activity and Functional Performance at the Age of 76

In a population study, involving 293 women and 233 men, the relation between level of physical activity in earlier life and both physical activity and performance at age 76 has been analysed. The life span was divided into five age periods from the age of 10 and described as competition sport, recreational sport, occupational physical load, household work and means of transportation. The results revealed that when all fields of activity were combined into a total measure of physical activity, created through weighting, the earliest periods alone could not explain activity patterns or performance late in life. After the age of 35 years in men and 50 years in women, however, the associations grew stronger and the activity level of the last life period (66-76) was strongly correlated to all variables incorporated in the study. When, on the other hand, each field of activity was treated alone, above all recreational sport turned out to be positively related to walking speed and physical activity at age 76 in both women and men for most life periods.

Long-term effects of home rehabilitation after hip fracture – 1-year follow-up of functioning, balance confidence, and health-related quality of life in elderly people

Purpose. To investigate the long-term effects of home rehabilitation (HR) after hip fracture in elderly people. Method. A randomized, controlled longitudinal study on geriatric hospital-based HR was compared with conventional care (CC) in 102 patients. Independence in activities of daily living (ADL), frequency of activity, basic physical performance, balance confidence, health-related quality of life, mood and perceived recovery were measured 6 and 12 months after discharge. Results. One year post-discharge the HR participants reported significantly higher degree of independence in self-care and locomotion, as well as of balance confidence in stairs and instrumental activities and perceived physical function, than the CC group. One year after discharge 14 persons (29%) in the HR group and five persons (9%) in the CC group considered themselves fully recovered. Conclusions. The positive long-term effects were more pronounced among the participants in the HR group than among those who received CC, possibly due to the early start of the HR programme in hospital and its focus on self-efficacy and training of daily activities. However, one year after discharge a mojority of participants in both groups did not consider themselves to be fully recovered when they compared to their situation before the fracture.

Effects of a physical and nutritional intervention program for frail elderly people over age 75. A randomized controlled pilot treatment trial

Background and aims: There are few studies published that combine the interventions of physical training and nutrition. The aim of the present study was to describe the impact of a physical and nutritional intervention program for frail community-dwelling elderly people over the age of 75. Methods: Ninety-six community-dwelling elderly people (58 women) were randomized to four different groups: i) a physical training program (aerobic, muscle strength, balance), ii) a nutritional intervention program (individually targeted advice and group sessions), iii) a combination of these interventions, and iv) a control group. At baseline subjects were screened for physical performance such as muscle strength, balance, mobility and activities of daily living, as well as nutritional aspects such as energy intake, body weight and fat-free mass. These measurements were repeated immediately after the intervention, which lasted for 12 weeks, and after another 6 months. Results: The intention-to-treat analysis indicated significant improvements in lower-extremity muscle strength in both training groups compared with the nutrition group at 1st follow-up. There were small significant changes for some of the balance measurements in the training group without nutrition treatment. The nutrition intervention did not show any significant results. Conclusions: This study shows the positive effect on lower-extremity muscle strength directly after the intervention. Balance training most probably needs to be more individualized in order to be effective for frail elderly people. Further studies are needed, with larger sample sizes, to investigate the effects of these types of interventions before any further conclusions can be drawn.

Balance function and fall-related efficacy in patients with newly operated hip fracture:

Objective: To investigate the relation between fall-related efficacy in daily-life activities and functional as well as instrumental tests of balance in patients with hip fracture. Design: Analysis of different aspects of balance using the Falls Efficacy Scale, Swedish version FES(S), questions on fear of falling, Functional Reach (FR) and tests on a balance platform (Chattanooga). Subjects: Fifty-five elderly inpatients (mean age 82.3) with newly operated hip fracture who were assessed during the last week in hospital before discharge. Results: The results showed a significant relationship between the subjective ability measured with the FES(S) and the objectively measured balance in the Functional Reach test and also between fall-related efficacy measured with FES(S) and fear of falling. Very few significant correlations were found between the results from balance tests on the force platform and those obtained with FES(S) and FR. Conclusions: Both the Falls Efficacy Scale, Swedish version, and the Functional Reach have been shown to be useful in analysing balance function in elderly patients newly operated on for hip fracture. The Falls Efficacy Scale also indicates which of the daily activities the patient perceives as troublesome and thus require further training.

Muscle strength testing with one repetition maximum in the arm/shoulder for people aged 75 + - test-retest reliability

Objective: To investigate the reliability of a muscle strength test of the arm/shoulder in elderly people, aged 75 and older, and to compare subjects with and without previous muscle strength training experience. Design: Reliability study - test-retest. Setting: Research centre for the elderly. Main measures: One repetition maximum (1 RM) was measured using an arm/shoulder strength-training device (Pull Down, Norway). Two measurements were conducted, approximately one week apart. Results: Forty people were included in the study and 34 completed both sessions. Eleven participants had previous muscle strength training experience on the indicated device. There was a high correlation between the test sessions, r = 0.97 for both groups. The analysis of 95% limits of agreement for the mean difference was -4.3/+6.9 kg for the group without and -3.0/+6.4 kg for the group with previous experience, respectively. Conclusion: One repetition maximum evaluated by the Pull Down device seems to be a reliable and safe method for dosing and evaluating a muscle strength training programme for elderly people. The observed variation of approximately -4/+7 kg cannot be interpreted as an effect of muscle training, but is more likely an effect of learning, fluctuations in daily condition and/or motivation.

Investigation into the reliability and validity of the measurement of elderly people's clinical walking speed: A systematic review

The number of available walking tests has increased dramatically over the past decades. Therefore, it is highly important to help clinicians choose the most appropriate walking test for a specific setting. This systematic review aimed to critically evaluate the reliability, validity, and responsiveness of clinical walking speed in a broad population of elderly persons living in the community, sheltered housing, or institutions. Literature searches were performed in several different databases. Key words were based on the topic of the measurement properties of performance-based clinical tools for quantifying walking. The instrument selected for review was walking speed. The methods and results of all the evaluated measurement properties were rated by using a standard checklist for appraising the qualitative attributes and measurement properties of the instrument. A total number of 3,781 abstracts were reviewed, and 86 articles were chosen for inclusion. Habitual walking speed seems to be highly reliable in community-dwelling people and residents in mixed settings. There have not been any studies that accord with our inclusion and exclusion criteria that have evaluated the reliability of maximum walking speed in an aged population. Walking speed is a highly valid test, both at habitual and maximum speed. Few studies gave information about responsiveness for walking speed, which means that these results cannot be evaluated properly. Habitual walking speed is a reliable measure, but maximum walking speed needs further evaluation. Both habitual and maximum walking speeds are valid instruments, and they predict death, hospitalization/institutionalization, and decline in mobility.

Effects of individually tailored physical and daily activities in nursing home residents on activities of daily living, physical performance and physical activity level: a randomized controlled trial.

Background: Nursing home residents are extremely inactive and deterioration in health and an increasing dependence in activities of daily living (ADL) are common. Physical activity and exercise play a major role in the preservation of physical function and quality of life late in life. However, evidence for the benefit of rehabilitation in nursing home residents is conflicting and inconclusive. Objective: To evaluate the effect of an individually tailored intervention program of 3 months, for nursing home residents, on ADL, balance, physical activity level, mobility and muscle strength. Methods: In this single-blind randomized clinical trial with parallel groups, nursing home residents >64 years of age from three Nordic countries were included. The intervention group (IG) was assigned to individually tailored physical and daily activities, while the control group (CG) received ordinary care. Primary outcomes were ADL and balance, and secondary outcomes physical activity level, mobility and muscle strength. Results: At baseline, 322 nursing home residents were included, of whom 266 were assessed after 3 months of intervention. Following the intervention, a significant difference was found between participants in the IG and CG on measures of balance, physical activity and transfers. The IG significantly improved walking/wheelchair speed and functional leg muscle strength. The CG had significantly deteriorated in ADL, balance and transfers. Persons who had taken part in the intervention for more than 150 min/week significantly improved their balance and physical activity level. Participation in more than 10 weeks of intervention significantly improved physical activity and walking/wheelchair speed, while a deterioration was seen in those who had participated less. Conclusion: Individually tailored intervention in nursing home residents focusing on physical and daily activities is effective in improving transfers, balance and physical activity level compared to usual care. The effect of the intervention is dependent on the total activity time.

Benign paroxysmal positional vertigo is a common cause of dizziness and unsteadiness in a large population of 75-year-olds

Background and aims: Studies have shown that 65% of people with dizziness may have a vestibular etiologic diagnosis, possibly benign paroxysmal positional vertigo (BPPV). The diagnosis of BPPV is based on medical history and findings after the Dix-Hallpike test. It is sometimes difficult to perform the Dix-Hallpike test in elderly persons, due to the limited range of motion when extending the neck. In this study, we used a side-lying test to stimulate the posterior semicircular canal, while the head and neck were fully supported on the examination table. The aims of this study were to investigate the prevalence of dizziness and/or impaired balance and BPPV in a population of 75-year-olds by means of a questionnaire and clinical tests, and to compare elderly persons with and without BPPV. Methods: A representative population sample of 675 persons completed a questionnaire about dizziness and 571 persons underwent side-lying, static balance and dynamic walking tests. Results: Subjective dizziness and/or impaired balance were found in 36% of subjects, especially when walking outdoors. A significant gender difference was found, with a higher prevalence in women (40%) compared with men (30%) (p<0.01). BPPV was found in 11% and was significantly more common in women (p<0.01). Elderly individuals with BPPV also displayed significantly impaired balance in static and dynamic balance tests compared with persons without BPPV (p<0.01). Persons with BPPV reported significantly more subjective problems with dizziness and balance compared with persons without BPPV (p<0.001). Conclusions: Subjective and objective unsteadiness, dizziness and BPPV are common in the elderly.