Wert, David M. MPT; Talkowski, Jaime B. PhD, MPT; Brach, Jennifer PhD, PT; VanSwearingen, Jessie PhD, PT, FAPTA
Community-dwelling older adults comprise a large portion of the general older adult population and are a significant part of ongoing research in aging.1 One characteristic that differentiates community-dwelling older adults from the general population of older adults is independence in daily activities and functioning, meaning that they do not require the assistance of another person to perform their basic day-to-day activities, such as bathing, toileting, dressing, cooking, and light housecleaning.2,3 In addition, among the independent community-dwelling older adults in our research, we recognized 2 groups, those in senior living residences (SLR) and those in individual community residences (ICR). We considered senior living residences to be carriage homes, apartment and room living in a senior facility or retirement community, with availability of services (ie, meals, laundry, light housecleaning, transportation, and internal and external housing maintenance) and adapted physical environments to promote mobility and reduce risk of injury.4-6 Individual community residences were defined as more traditional home and apartment living that does not include services as part of the home ownership or rental agreement. The primary reliance is on self, family, or friends for activities within the home and community.
The 2 groups, based on residences (SLR and ICR), are rarely distinguished in studies of community-dwelling older adults,7-9 and established definitions of subgroups by residence have not been found. However, based on reports of how and why older adults choose a place of residence,10,11 findings and interpretation of results may be influenced by differences in living environment for the 2 groups.
Social support and mobility often impact the decision of older adults to transition from a traditional, individual community home setting to a senior living environment10,11 that, although independent living, has services to support daily living and is available as part of the residence. It is reasonable to expect, given the potential social and mobility-based decision for the transition, that differences in physical (ie, gait and physical activity) and psychosocial (fear of falling and confidence in walking) characteristics may exist between the 2 groups. Researchers who report on physical and psychosocial outcomes of community-dwelling older adults may misrepresent this subgroup of older adults because of differences in physical and psychosocial function based on type of residence. Understanding potential differences in performance by residence may be important in selecting older adults most appropriate for a study and in accurately interpreting results.12
Observing SLR and ICR differences within one of our intervention studies, we were interested in exploring the apparent differences. We performed a secondary analysis and examined the baseline data for physical and psychosocial characteristics and fall history of 2 samples of community-dwelling older adults with mobility disability. We expected the older adults living in SLR compared with those living in ICR to have poorer walking abilities, be less physically active, be more fearful of falling, be less confident with walking, and report more falls.
We performed a secondary analysis of the baseline data from our recent intervention studies13 of independent community-dwelling older adults with mobility disability. The investigations, whose aim was to improve walking, compared 2 interventions: (1) traditional impairment-based program of endurance, strength, and balance training and (2) a motor learning program that promoted smooth, automatic movement and movement adaptations to altered conditions. Inclusion and exclusion criteria for the intervention studies were the same, and baseline measures were collected in a single session.
Participants for this secondary analysis of community-dwelling older adults served as the 2 primary samples for the intervention study,13 whose aim was to improve walking. The intervention study was performed at a senior living facility for independent older adults and at the Senior Mobility Aging and Research Training (SMART) Center at the University of Pittsburgh. All older adults living in the senior living facility served as the SLR group (n = 18, mean age = 83.9 years, 83% women). The sample of older adults from the SMART Center served as the ICR group (n = 41, mean age = 77.5 years, 61% women). All participants consented to participate in the study, and protocols were approved by the University of Pittsburgh institutional review board.
To be eligible for participation, individuals must have met all of the following inclusion criteria: 65 years of age and older, ambulatory with an assistive device other than a straight cane and without the assistance of another person; have written approval/clearance from their physician to participate in low- to moderate-intensity, supervised exercise; and have difficulty with walking or balance as indicated by mild to moderate slowing of walking speed (between 0.6 m/s and 1.0 m/s) and variable gait (step length coefficient variability > 4.5% or step width variability < 7% or > 30%). In addition, individuals were excluded if they had dyspnea at rest or used supplemental oxygen, had acute illness or uncontrolled cardiovascular disease, had diagnosed dementia or cognitive impairment defined as a Mini-Mental State Examination score of less than 24, were recently hospitalized for cardiac reasons or for any reason for more than 3 days, had hemiparesis with lower extremity strength of less than 4 to 5 (MMT grade), had a fixed or fused lower extremity joint or amputation, or had a progressive motor disorder such as multiple sclerosis or Parkinson disease.
Demographic information collected during the study included age, level of education (none, elementary, high school, college, graduate, other), gender, race, living arrangement (lives alone: yes or no), and number of comorbidities (Comorbidity Index, 0 = minimum and 18 = maximum number of comorbidities per person). Gait speed and self-reported performance-based measures, described below, were collected by physical therapists experienced with the measure.
Gait speed was measured by using the GaitMat II (EQ, Inc, Chalfont, Pennsylvania), a computerized walkway approximately 6 m in length, with the middle 4 m for data collection. Participants walked at usual, self-selected walking speed on the instrumented walkway for 2 practice walks, followed by 2 passes for gait characteristic data collection.8,12
Physical activity was recorded by using an accelerometer (ActiGraph GTIM, Actigraph, LLC, Fort Walton Beach, Florida), an electronic sensor for recording and storing the intensity, frequency, pattern, and duration of ambulatory physical activity.9,14–16 Accelerometers were attached to clothing at waist level over the dominant hip, during waking hours for 7 consecutive days. Physical activity was calculated as the mean over 7 days of the average counts per minute (CPM) worn. Accelerometer data have been validated in both laboratory and free-living conditions as a measure of physical activity.17-19
Activity and activity restriction. The activity subscale and activity restriction subscale of the Survey of Activity and Fear of Falling in the Elderly (SAFFE) is an interviewer-administered instrument for measuring fear of falling and activity/activity restriction in basic and instrumental activities of daily living related to fall-related fear.20 The activity subscale (score, 0–11) is represented by the number of activities out of the 11 that they currently participate in, whereas activity restriction is the sum of activities reported as having been done less over the past 5 years (score, 0–11).
Fear of falling was measured in 2 ways: the SAFFE Fear subscale20,21 and a yes and no response to the question “Are you afraid of falling?”22,23 The SAFFE Fear subscale was used as one indicator of fear of falling. The SAFFE Fear subscale gives the mean score for fear across the 11 activities (0, not worried, to 3, very worried). Scale validation was reported by Lachman et al,20 who showed that SAFFE Fear subscale score was significantly correlated with Tinetti Fall Efficacy Scale score and 1-item Afraid of Falling Question. In addition, construct validity was obtained by Lachman et al,20 by looking at fear in relation to activity restriction; higher fear scores equated with greater activity restriction. Howland et al20,21 reported values of SAFFE fear that distinguished level of fear and degree of activity restriction; values greater than 0.40 significantly defined adults as being fearful. Lachman et al20 reported mean SAFFE Fear of Falling subscale score of 0.66 (SD = 0.69) for community-dwelling older adults in public senior housing developments (n = 270).20
Confidence in walking was measured by using the Gait Efficacy Scale, an index of confidence in walking over various surfaces and conditions. Item scores (1 = no confidence to 10 = complete confidence) for each of the 10 conditions are summed for a total Gait Efficacy Scale score ranging from 10 to 100 and previously validated as a measure of confidence in walking.23,24
Fall history was determined by the participant's report of the number of falls experienced in the past year, with 1 or more falls classified as a positive fall history.
Descriptive statistics were performed to describe characteristics of the older adults by residence. Independent t tests for continuous data and &b.chi;2 for categorical data were calculated to test for differences in measures between individuals in SLR and ICR (SPSS, version 14.0).
Participants differed by residence for age, living arrangements, and number of comorbidities (Table 1). Older adults in SLR were older, were more likely to live alone, and had more comorbidities. Similarities between the SLR and ICR groups also existed; participants were primarily whites, women, and had 4 or more years of college education.
All older adults studied walked slowly, with gait speed similar for older adults in SLR and ICR. Likewise, physical activity and SAFFE activity were similar for older adults in SLR and ICR (Table 2).
Psychosocial Measures and Fall History
Individuals in SLR compared with those in ICR reported less fear of falling, with 22% (4/18) of older adults in SLR and 54% (22/41) of older adults in ICR scoring fearful (≥0.40).20,21 Fewer older adults in SLR than those in ICR reported falling in the past year (Table 2). There was no difference in walking confidence between groups.
As expected, older adults in SLR were older and had greater disease burden than those in ICR. The findings are consistent with a previous study that examined differences among older adults across various living environments.25 We did not expect the older adults in SLR, with greater disease burden and older age, to have similar gait speed and physical activity as their counterparts in ICR, nor did we expect those in SLR to report less fear of falling and have a lower percentage reporting falls compared with those in ICR. The unexpected differences in physical function and psychosocial aspects may be an impact of the differences in residential environment.
In previous studies, investigators have demonstrated associations between environmental conditions, fear of falling, and physical activity.26-32 Older adults who perceive the external environment as less safe typically report more fear of falling and are less likely to be physically active than older adults living in perceived safe environments.26-30 In addition, Huang31 recognized predictors of in-home hazards for falling, which included living in an urban area, fear of falling, being older (older than 75 years), and having poor gait and balance.31 Together, the studies reveal that the fear of falling, associated with external environmental factors and in-home hazards, presents a barrier to physical function and physical activity levels of older adults.
SLR were designed in part to reduce barriers to walking, physical function, and activity for older adults by enhancing the physical surrounding for ease of navigation. Additionally, SLR offer their residents access to services (ie, cleaning and laundry service, landscape management, meal plans, and transportation accessibility) that may reduce the need for residents to participate in at-risk activities, including yard work, home maintenance, vigorous housecleaning, and stair negotiation. The enhanced environment may, in turn, create a sense of security, enabling residents of SLR to be more active in their environment. The sense of security may have influenced older adults in SLR to report a lower fear of falling than those in the ICR group (SAFFE Fear subscale score 0.24 vs 0.50). The lower perceived fear of falling reported by older adults in SLR than by those in the ICR group and, secondarily, the lesser fear may have also impacted gait speed and physical activity levels. For example, older adults in SLR were older and had a greater number of comorbidities, both factors associated with poorer physical function, yet gait speed and physical activity were similar between groups by residence.
Alternatively, the similar mean gait speed and activity for adults in SLR compared with those in ICR may be directly related to the supportive environment of the SLR. For residents in SLR, easy access to indoor walking areas (hallways) and fitness center; walking to meal, social events, and mailbox; and volunteer opportunities within the residential community may promote physical activity. Seventy-two percent of older adults in SLR reported greater participation in “walking for exercise” (SAFFE activity) than did older adults living in ICR (61%). Of the older adults who walked for exercise, only 15% of SLR adults compared with 40% of ICR adults were “worried that they may fall.” Walking for exercise for older adults in ICR may be more difficult, including the need to climb stairs and traverse uneven surfaces. Older adults in ICR who attempt the physical activity or functions similar to those in SLR may encounter environmental challenges, eliciting greater fear of falling, with a negative impact on physical activity and falls. Older adults living in ICR had a higher percentage of participation in “going out when it's slippery,” “visiting friends and relatives,” and “going out in crowds” than did their SLR counterparts. However, 87% of ICR older adults who went out when slippery, 26% who visited friends and family, and 27% who went out in crowds were worried that they may fall while doing these activities. This was compared with older adults living in SLR, who reported 71%, 13%, and 0% worry, respectively. Enhanced physical surroundings and reduced need for participation in at-risk activities may, in turn, account for the lower number of older adults reporting falls in SLR (33%) than in ICR (44%).
A unique strength of this cross-sectional study is that it is one of the few studies to explore the independent community- dwelling population of older adults based on type of residence. Previous work has been conducted to explore differences between independent community-dwelling older adults and assisted living and nursing home residents, but little has been done to study differences within the independent older adult population, which may be important in planning services and providing guidance to enable older adults to live healthy and independently as possible. A second strength is the study of physical function of community-dwelling older adults in SLR and ICR, independent of one another, yet in the same geography and climate environment.
Primary limitations of the study relate to whether the sample of older adults in SLR and ICR represents community-dwelling older adults in the population and the size of our sample. The SLR studied may not be representative of all SLR, relative to the environment and services provided as well as characteristics of the residents, such as socioeconomic status, race, and gender. This study is a secondary analysis; defining differences between the older adults by residence may have been limited by inadequate power. Subanalyses, stratifying within residence by fearful and not fearful, could not be explored given the small sample size. In addition, we were unable to quantify the specific degree and/or type of assistance either group received with its daily activities. Therefore, our findings are best interpreted within our defined groups of SLR and ICR. Prospective study designs may benefit from consideration of such issues to better understand similarities or differences between older adults by the type of residence.
Older adults living in SLR compared with those in ICR had similar physical function (gait speed and physical activity) but differed in report of fear of falling and fall history. Recognizing the possible differences in physical and psychosocial function by place of residence may be important for researchers conducting studies or health care delivery services for community-dwelling older adults.
This work was supported by the Pittsburgh Claude D. Pepper Older Americans Independence Center (grant P30 AG024827).
2. Katz S, Akpom CA. A measure of primary sociobiological functions. Int J Health Serv. 1976;6:493–507.
3. Jakobsson U. The ADL-staircase: further validation. Int J Rehabil Res. 2008;31:85–88.
7. Cress M, Schechtman K, Mulrow C, Fiatarone MA, Gerety MB, Buchner DM. Relationship between physical performance and self-perceived physical function. J Am Geriatr Soc. 1995;43:93–101.
8. Brach J, Berthold R, Craik R, VanSwearingen JM, Newman AB. Gait variability in community-dwelling older adults. J Am Geriatr Soc. 2001;49:1646–1650.
9. Trost S, McIver K, Russell R. Conducting accelerometer-based activity assessments in field-based research. Med Sci Sports Exerc. 2005;37:S531-S543.
10. Litwak E, Longino CF. Migration patterns among the elderly: a developmental perspective. Gerontologist. 1987;27:266–272.
11. Jackson D, Longino C, Zimmerman R, Bradsher J. Environmental adjustments to declining functional ability. Res Aging. 1991;13:289–309.
12. Barker S, Craik R, Freedman W, Herrmann N, Hillstrom H. Accuracy, reliability, and validity of spatiotemporal gait analysis system. Med Eng Phys. 2006;28:460–467.
13. VanSwearingen JM, Perera S, Brach JS, Cham R, Rosano C, Studenski SA. A randomized trial of two forms of therapeutic activity to improve walking: effect on the energy cost of walking. J Gerontol Med Sci. 2009;64:1190–1198.
14. Laporte RE, Montoye HJ, Casperson CJ. Assessment of physical activity in epidemiologic research: problems and prospects. Public Health Rep. 1985;100:131–146.
15. Welk GJ, Blair SN, Wood K, Jones S, Thompson RW. A comparative evaluation of three accelerometry-based physical activity monitors. Med Sci Sports Exerc. 2000;32:S489-S497.
16. Starling RD. Use of doubly labeled water and indirect calorimetry to assess physical activity. In: Welk GJ, ed. Physical Activity Assessments for Health-Related Research. Champaign, IL: Human Kinetics; 2002.
17. Welk GJ, Corbin CB. The validity of the Tritrac-R3D activity monitor for the assessment of physical activity, II: temporal relationship among objective assessments. Res Q Exerc Sport. 1998;69:395–399.
18. Janz KF. Validation of the CSA accelerometer for assessing children's physical activity. Med Sci Sports Exerc. 1994;26:369–375.
19. Bouten CV, Verboeket-van de Venne WP, Westerterp KR, Verduin M, Janssen JD. Daily physical activity assessment: comparison between movement registration and doubly labeled water. J Appl Physiol. 1996;81:1019–1026.
20. Lachman ME, Howland J, Tennstedt S, et al. Fear of falling among the community-dwelling elderly (SAFE). J Gerontol B Psychol Sci Soc Sci. 1998;53:P43-P50.
21. Howland J, Peterson EW, Levin WC, Fried L, Pordon D, Bak S. Fear of falling among the community-dwelling elderly. J Aging Health. 1993;5:229–243.
22. Myers AM, Powell LE, Make BE, et al. Psychological indicators of balance confidence: relationship to actual and perceived abilities. J Gerontol A Biol Sci Med Sci. 1996;51:M37-M43.
23. Tinetti ME, Richman D, Powell L. Falls efficacy as a measure of fear of falling. J Gerontol B Psychol Sci Soc Sci. 1990;45:P239-P243.
24. McAuley EM, Mihalko SL, Rosengren K. Self-efficacy and balance correlates of fear of falling in the elderly. J Aging Phys Act. 1997;5:329–340.
25. Cyarto E, Myers A, Tudor-Locke C. Pedometer accuracy in nursing home and community-dwelling older adults. Med Sci Sports Exerc. 2004;36:205–209.
26. Yen IH, Yelin EH, Katz P, Eisner MD, Blanc PD. Perceived neighborhood problems and quality of life, physical functioning, and depressive symptoms among adults with asthma. Am J Public Health. 2006;96:873–879.
27. Yen IH, Kaplan GA. Neighborhood social environment and risk of death: multilevel evidence from the Alameda County study. Am J Epidemiol. 1999;149:898–907.
28. Diez Roux AV, Evenson KR, McGinn AP, et al. Availability of recreational resources and physical activity in adults. Am J Public Health. 2007;97:493–499.
29. Wilcox S, Bopp M, Oberrecht L, Kammermann SK, McElmurray CT. Psychosocial and perceived environmental correlates of physical activity in rural and older African American and white women. J Gerontol B Psychol Sci Soc Sci. 2003;58:P329-P337.
30. Piro F, Noss O, Claussen B. Physical activity among elderly people in a city population: the influence of neighborhood level violence and self-perceived safety. J Epidemiol Community Health. 2006;60:626–632.
31. Huang TT. Home environmental hazards among community-dwelling elderly persons in Taiwan. J Nurs Res. 2005;13:49–57.
32. Gitlin L, Winter L, Dennis M, et al. A randomized trial of a multicomponent home intervention to reduce functional difficulties in older adults. J Am Geriatr Soc. 2006;54:809–816.
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