The promotion of physical activity is an important nonpharmaceutical strategy in chronic disease management.1 Physical activity interventions, whether targeting older adults2,3 or the general population,4 are thought to be vitally important for attenuating the risks for and ameliorating the consequences of many health conditions (eg, cardiovascular disease, obesity, diabetes, cancer, arthritis, and depression).5,6 Despite these efforts, older adults generally remain among the least physically active of any adult age group,6–8 with more than half not attaining the amount of physical activity recommended for their age.9
Numerous determinants of older adult physical activity have been identified, including many characteristics of the individual, social environment, physical environment, and cultural environment.10–12 For some older adults with balance impairments, however, self-imposed activity avoidance represents an additional determinant, given its association with falls, fear of falling, and low fall-related self-efficacy.13–18 Activity avoidance, in turn, has been associated with depression and social isolation.19–22 Strategies for addressing the unique barriers to physical activity among individuals with balance impairments are important considerations for health promotion and rehabilitation.
Positive social relationships with close companions (eg, spouse, partner, family member, or caregiver) seem to have a protective effect on physical function and physical disability23 and may increase the intention to be physically active and adherence to exercise classes.24,25 A possible explanation for this effect is that structure and function of social connections contribute to individual self-efficacy.26,27 The extent to which positive social relationships might influence the physical activity of older adults with balance impairments, especially those impairments that challenge fall-related self-efficacy and lead to physical activity restriction,17,28 has not been studied.
To begin examining this issue, our first aim was to explore how confidence in an older adult's balance capability might differ between 2 perspectives: that of the older adult and that of his or her close companion. Our second aim was to explore how companion confidence in the balance capability of an older adult might serve as a potential determinant of older adult physical activity. To conduct the study, we recruited older adult—companion dyads and administered 2 versions of the Activities-Specific Balance Confidence (ABC) scale.29 Older adults completed the traditional version, whereas companions completed a modified version that we created specifically for this study. Older adults also completed the Physical Activities Scale for the Elderly (PASE).30 We hypothesized that perceptions of confidence in the older adult's balance capability would be relatively similar, especially for pairs who spent substantial time together each week. We also hypothesized that companions with relatively higher confidence in the older adult's balance capability would be associated with physically active older adults, whereas companions with relatively lower confidence would be paired with less physically active older adults.
Design and Participants
The study employed a cross-sectional design in which dyads formed by a community-dwelling older adult and his or her close companion were recruited as a sample of convenience. Older adult participants were at least 60 years of age and identified their companion as “someone with whom they have spent at least 7 hours per week during the last month.” Dyads were recruited via word of mouth and posted flyers from the Greater Portland, Maine, area. Many were recruited at local independent living facilities. Every effort was made to recruit a range of companion types, that is, those who shared a residence with the older adult participant (eg, spouse, partner, and sibling) and those who did not (eg, extended family and friend). Dyads were excluded if either individual (1) was unable to speak English, (2) reported cognitive, memory, or communication impairments that limited his or her ability to complete surveys, or (3) if the targeted older adult participant was nonambulatory. The Institutional Review Board for the Protection of Human Subjects at the University of New England approved the study. Data were collected from July through November 2011.
We recorded the age and sex of each participant, whether dyad members shared a residence, the nature of the relationship (eg, spouse, friend, family member, and caregiver), the approximate number of hours per week spent together during the previous month, and the number of times the older adult participant had fallen in the previous year. To characterize older adult ambulatory mobility, we collected 2 trials of self-selected gait speed over a 3-m distance; assistive devices were allowed as needed.31
Activities-Specific Balance Confidence Scale
The ABC is a 16-item survey that examines balance confidence during a series of progressively more challenging balance tasks, from ambulatory activities inside the home to walking in various community environments.29 Modeled after Bandura's self-efficacy framework,27 respondents rate their confidence in response to the root question, “How confident are you that you will not lose your balance or become unsteady when you...?” Each item is rated from 0 (no confidence) to 100 (complete confidence). A total score is calculated as the mean of the individual item scores. In the original report of its development, the ABC scale demonstrated high internal consistency (Cronbach α = 0.96), test-retest reliability (r = 0.92), convergent and discriminative validity in comparison to scales of self-perceived physical ability and emotionality, and the ability to discriminate between seniors reporting high or low mobility.29 Additional evidence of its validity and reliability was later summarized.32
We administered the traditional ABC scale to older adult participants and generated a total score (ie, ABCOlder Adult). For companion participants, we modified the root question of the ABC scale to read, “How confident are you that [insert older adult name] will not lose [his/her] balance or become unsteady when [he/she]...?” The item list and scoring of the modified version remained unchanged, so as to produce a comparable score (ABCCompanion). To our knowledge, the modified version of the ABC scale was unique to this study and had not been validated previously.
Physical Activity Scale for the Elderly
The PASE is a brief survey designed to measure physical activity in persons 65 years and older during leisure, household, and occupational activities occurring over the previous 7-day period.30 PASE item scores are calculated by multiplying either time spent (hours per week) or participation in (yes/no) each activity with empirically derived item weights. The total PASE score, which represents the sum of individual item scores, ranges from 0 to more than 400. In early publications, the PASE demonstrated good test-retest reliability (r = 0.75) and construct validity in relation to physical measures and self-perceptions of health status in samples of community-dwelling older adults.30,33 Additional evidence of its validity and reliability was summarized more recently.34
Trained research personnel collected descriptive data and administered the ABC scale to each older adult and companion dyad in a place convenient to them (eg the older adult's home). Participants were sequestered from one another when completing the surveys to avoid influencing each other's responses. Older adults also completed the PASE and underwent gait speed testing.
Data were analyzed using SPSS version 20 (SPSS Inc, Chicago, IL). Descriptive statistics (ie, mean, standard deviation [SD], and frequency) were used to characterize the sample. Gait speed was calculated as the mean of 2 trials. Time spent together and the number of falls in the previous year were characterized using the average reported value, to account for the possibility of recall error by either participant. For our first aim, we characterized the agreement between and correspondence of ABCOlder Adult and ABCCompanion scores using mean difference (95% confidence interval [CI]), dependent samples t test (α = 0.05), and the intraclass correlation coefficient 1-way random effects model. Because of a skewed distribution in the amount of time spent together, we used the relatively conservative, nonparametric Spearman ρ correlation coefficient to analyze its relationship to the differences in the ABC scores. We constructed a Bland–Altman plot35 and calculated the 95% limits of agreement to identify systematic bias in and outlier cases of marked difference in paired ABC scores. For our second aim, we analyzed the relationship between each ABC score and the PASE score of the older adult using the Pearson product-moment correlation coefficient (α = 0.05).
The sample contained 22 female and 18 male older adult participants, who had a mean age ± SD of 80.7 ± 7.5 years. Mean gait speed ± SD was 0.82 ± 0.26 m/s. One dyad did not provide falls data; another dyad reported multiple daily falls; 22 dyads reported 0 falls. The median value of the resulting highly skewed distribution of older adult falls was 0.5.
The sample contained 33 female and 7 male companions, who had a mean age ± SD of 69.2 ± 14.4 years. Two companions did not report their age. Twenty-five companions reported living with the older adult. Mean time spent per week together ± SD was 90.7 ± 62.3 hours, with 19 dyads reporting spending more than 100 hours per week together. Companions included 21 spouses, 11 children, 6 friends, and 2 unrelated caregivers.
Older adults as a group were more confident in their balance capability (mean ABCOlder Adult = 70.0; 95% CI = 62.8−77.2; SD = 22.4; minimum = 14.4; maximum = 100.0) than the group of companions (mean ABCCompanion = 60.2; 95% CI = 50.6−69.8; SD = 30.0; minimum = 2.2; maximum = 99.7). The difference between group mean scores was significant (mean difference = 9.8; 95% CI = 2.3−17.3, t (39) = 2.38; P = 0.02). The 2 sets of scores were significantly yet moderately associated (intraclass correlation coefficient (1,1) = 0.56; 95% CI = 0.31−0.74; P < 0.001). Time spent together was not associated with the difference in ABC scores (ρ = 0.19; P = 0.25).
Figure 1 features a Bland–Altman plot35 in which mean of paired scores (x-axis) was plotted against difference in paired ABC scores (y-axis). Positive differences (n = 25) indicated cases in which older adults were more confident in their balance capability than their companion (mean difference = 21.9; 95% CI = 13.5−30.3). Negative differences (n = 15) indicated cases in which companions were more confident in their older adult's balance capability than the older adult himself or herself (mean difference = 10.5; 95% CI = 4.6−16.4). Eleven dyads had ABC score differences more than 20. Four outlier dyads were identified in which the difference in paired ABC score was more than 46.9, the 95% limits of agreement. Each outlier dyad featured an older adult who was markedly more confident than his or her companion.
Physical activity levels among older adult participants were variable and relatively low (mean PASE score = 81.7; 95% CI = 63.4−100.0; SD = 57.2; minimum = 2.25; maximum = 271.2). ABCOlder Adult was significantly yet weakly related to the PASE score (r = 0.33; 95% CI = 0.02−0.64; P = 0.04). The association between companion confidence in older adult balance capability and older adult physical activity was relatively stronger (r = 0.51; 95% CI = 0.23−0.79; P = 0.01). To further explore this relationship, we formed 2 subgroups using older adult–companion dyads with the greatest discrepancy in ABC scores. Subgroup A (n = 10) contained the most disparate cases in which older adults were more confident in their balance capability than their companion. Subgroup B (n = 10) contained the most disparate cases in which companions were more confident in the older adult's balance capability than the older adult himself or herself. In a secondary analysis (Table 1), we determined that for subgroup A, ABCCompanion was significantly and more strongly related to the older adult PASE score (r = 0.70; 95% CI = 0.12−1.00; P = 0.02) than ABCOlder Adult (r = 0.42; 95% CI = −0.33−1.00; P = 0.23). In contrast, for subgroup B, the relationships between ABCCompanion and older adult PASE scores, and between ABCOlder Adult and PASE scores, were weak and not statistically significant.
The purpose of this study was to explore companion confidence in the balance capability of an older adult as a potential determinant of older adult physical activity. We were fortunate to have recruited a sample of older adults who reported a range of balance confidence, consistent with individuals living with chronic health conditions representing a continuum from low to high functioning.36 Physical activity levels in the sample also varied, and the sample was relatively inactive in comparison to associated normative PASE values.37 Although the median number of reported falls among older adults was relatively low, the mean gait speed value suggested that many of them had an elevated risk of future adverse health events.31 Taken together, these sample characteristics supported both the internal validity of the correlation analyses (ie, a sufficient range of values for each variable) and the generalizability of the findings to the broader population of older adults with balance impairments.
Our hypothesis that older adults and their companions would similarly perceive the older adults' balance capability was not strongly supported as a general statement. Time spent together did not seem to be a contributing factor. Although paired ABC scores corresponded moderately across the sample, the amount of agreement seemed to depend somewhat on the mean of the paired ABC scores (Figure 1). All pairs reporting high confidence (ie, mean ABC scores >80) agreed relatively closely in their perceptions (ie, ABC score difference <1 SD). In most of these cases, the difference in ABC scores was less than 10 points. Among pairs reporting relatively lower confidence (ie, mean paired ABC scores <80), there was a greater incidence of substantial disagreement. Especially for the less confident group, older adults tended to be more confident in their balance capability than their companions. Taken together, these findings suggest that high balance confidence, which previously has been associated with high levels of older adult physical function,17,28,36 seems to be a shared perception among familiar observers. Low balance confidence, in contrast, does not necessarily seem to be similarly perceived. We speculated that such discrepant perceptions, and their lack of association with less time spent together, could have been attributed to companion uncertainty about the impact of chronic health conditions on older adult physical function.
Our results supported the previously articulated premise that reduced balance confidence and similarly elevated fear of falling seem to contribute to reduced physical activity among community-dwelling older adults.17,38–41 In addition, we confirmed the relatively weak yet significant correlation between ABCOlder Adult and PASE scores.38,39 Our hypothesis that companion confidence would be positively associated with older adult physical activity was generally supported (Table 1). In fact, companion confidence was more strongly associated with older adult physical activity than older adult confidence. Moreover, the strength of the association increased when restricting the analysis to dyads containing companions who were markedly more conservative in their confidence regarding the older adult's balance capability than the older adult himself or herself. Although it is possible that these particular older adults may have been overconfident of their true physical ability, no previous literature existed to support such an interpretation.
Clinical Implications and Future Directions
The results of our study have implications for clinical practice and future research. First, older adults and their companions do not necessarily share similar confidence in the older adult's balance capability. Especially for older adult patients presenting with chronic health conditions, discrepant perceptions between the patient and a familiar observer (eg, family member) are not unusual42 and should trigger further investigation into the factors underlying the discordance. Second, companion confidence in older adult balance capability shows promise as a relatively potent predictor of older adult physical activity, especially for cases in which the confidence level of the companion is markedly lower than that of the older adult. Finally, we believe our results, although preliminary, raise the possibility that companion confidence in an older adult's physical abilities might influence older adult self-efficacy for physical activity. We speculate, for example, that a companion who shares a similar level of confidence with an older adult may reinforce the older adult's level of self-efficacy, whether high or low. In contrast, discrepancies in confidence between an older adult and a companion may alter an older adult's self-efficacy, either raising it or lowering it depending on the nature of the social relationship between those involved. The basis for this proposition has been reported previously24,25 and warrants further investigation.
Our study was limited in several ways. The sample was restricted to older adult participants with an identified companion. Although companions as a group represented a range of social relationship types, some companions may have been much more familiar with their older adult than others. Undetected cognitive impairments among older adults and companions may have confounded the results. Physical activity instruments such as the PASE are potentially prone to recall error. The modified version of the ABC scale for use with companions lacked prior evidence of validity and reliability. No standardized definition of a fall was used to promote consistency of responses. Future investigations should consider these limitations in their study designs.
Older adults and their companions did not necessarily share similar confidence in the older adult's balance capability. Companion confidence, especially when markedly less than older adult confidence, showed promise as a predictor of older adult physical activity. Study findings provided a foundation for future investigations that focus on the effect of social relationships on the self-efficacy of older adults with balance impairments.
The authors thank the study participants, who gave generously of their time and graciously welcomed the research team into their lives. The work was sponsored by the Department of Physical Therapy of the University of New England in Portland, Maine.
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