Assessment of Functional Mobility After COVID-19 in Adults Aged 50 Years or Older in the Canadian Longitudinal Study on Aging.

Importance: The association of COVID-19 not requiring hospitalization with functional mobility in community-dwelling adults above and beyond the impact of the pandemic control measures implemented in 2020 remains to be elucidated. Objective: To evaluate the association between a COVID-19 diagnosis and change in mobility and physical function of adults in Canada aged 50 years or older during the initial pandemic lockdown. Design, Setting, and Participants: This population-based cohort study used data from the Canadian Longitudinal Study on Aging (CLSA) COVID-19 study. This study was launched on April 15, 2020, and the exit questionnaires were completed between September and December 2020. Prepandemic data from the first CLSA follow-up (2015-2018) were also used. Respondents included middle-aged and older community-dwelling participants residing in Canadian provinces. Data were analyzed from February to May 2021. Exposures: The assessment for self-reported COVID-19 status was adapted from the Public Health Agency of Canada and the Centers for Disease Control and Prevention case definition available at the time of data collection; cases were classified as confirmed or probable, suspected, or non-COVID-19. Main Outcomes and Measures: Changes in mobility since the start of the COVID-19 pandemic were assessed using global rating of change in mobility scales at the COVID-19 exit questionnaire. Participant-reported new onset of difficulty in 3 physical function tasks was also examined. Results: Among 51 338 participants at baseline, 21 491 participants (41.9%) were 65 years or older and 26 155 participants (51.0%) were women and 25 183 (49.1%) were men. Of 2748 individuals with confirmed or probable or suspected COVID-19, 113 (94.2%) were not hospitalized. Individuals with confirmed or probable COVID-19 had higher odds of worsening mobility in terms of ability to engage in household activity (odds ratio [OR], 1.89; 95% CI, 1.11-3.22), physical activity (OR, 1.91; 95% CI, 1.32-2.76), and standing up after sitting in a chair (OR, 2.33; 95% CI, 1.06-5.11) compared with adults without COVID-19 during the same pandemic time period. Similar results were found for suspected COVID-19 status (eg, household activity: OR, 2.09; 95% CI, 1.82-2.41). Conclusions and Relevance: This cohort study among older adults in Canada found that receiving a COVID-19 diagnosis was significantly associated with worse mobility and functioning outcomes even in the absence of hospitalization. These findings suggest that interventions may be needed for individuals with mild to moderate COVID-19 who do not require hospitalization.

A Brief Measure of Life Participation for People with COPD: Validation of the Computer Adaptive Test Version of the Late Life Disability Instrument.

Computer-adaptive tests use respondents' answers to previous questions to select the subsequent questions. They are gaining popularity for their increased measurement precision and decreased administration time compared to static questionnaires. The purpose of this study was to estimate the test-retest reliability and construct validity of the computer-adaptive test version of a participation measure, the Late Life Disability Instrument (LLDI-CAT) for people with COPD and to compare scores and administration time with those of the static LLDI. Among 76 older adults with COPD, scores on the LLDI-CAT were compared to scores on measures of related constructs, between groups based on symptom severity, prognosis and frailty phenotype, and to scores on the static LLDI. A subsample of 28 people completed the LLDI-CAT a second time within one week of the initial administration for test-retest reliability. The LLDI-CAT had very good test-retest reliability (ICC2,1 0.88; SEM 2.74 points), fair correlations with physical function (r = 0.37-0.50), anxiety (r=-0.42), and depression (r=-0.50), fair to moderately-strong correlations with quality of life (r = 0.48-0.63), and strong correlation with the static LLDI limitation domain (r = 0.80). The LLDI-CAT scores differed between people with different symptom severity, prognosis and frailty phenotype (p ≤ 0.004). The mean administration time for the LLDI-CAT was 3.3 (1.5) minutes, less than that of the static LLDI at 6.3 (2.8) minutes (p < 0.001). The LLDI-CAT demonstrates evidence of test-retest reliability and construct validity, and correlates well with the limitation domain of the static LLDI for people with COPD. The LLDI-CAT can be used to assess participation for this population.

Content validity of preference-based measures for economic evaluation in chronic obstructive pulmonary disease.

BACKGROUND: Generic preference-based measures (GPBMs) are health-related quality of life (HRQoL) measures commonly used to evaluate the cost-utility of interventions in healthcare. However, the degree to which the content of GPBMs reflect the HRQoL of individuals with chronic obstructive pulmonary disease (COPD) has not yet been assessed. The purpose of this study was to examine the content and convergent validity of GPBMs in people with COPD. METHODS: COPD patients were recruited from healthcare centers in Ontario, Canada. The Patient-Generated Index (PGI) (an individualized HRQoL measure) and the RAND-36 (to obtain SF-6D scores; a GPBM) were administered. Life areas nominated with the PGI were coded using the International Classification of Functioning Disability and Health and mapped onto GPBMs. RESULTS: We included 60 participants with a mean age of 70 and FEV1% predicted of 43. The mean PGI score was 34.55/100 and the top three overarching areas that emerged were: 'mobility' (25.93%), 'recreation and leisure' (25.19%) and 'domestic life' (19.26%). Mapping of the nominated areas revealed that the Quality of Well-Being scale covered the highest number of areas (84.62%), Health Utilities Indices covered the least (15.38% and 30.77%) and other GPBMs covered between 46 and 62%. A correlation of 0.32 was calculated between the SF-6D and the PGI. CONCLUSIONS: The majority of GPBMs covered approximately half of the areas reported as being important to individuals with COPD. When areas relevant to COPD are not captured, HRQoL scores generated by these measures may inaccurately reflect patients' values and affect cost-effectiveness decisions.

Randomized controlled trial of community-based, post-rehabilitation exercise in COPD.

PURPOSE: Although pulmonary rehabilitation (PR) improves function in people with chronic obstructive pulmonary disease (COPD), a community-based exercise program may be necessary to maintain functional capacity. We aimed to determine the effectiveness of a post-rehabilitation, community-based maintenance program on exercise tolerance, functional capacity and quality of life. METHODS: Patients with COPD who completed PR were randomized to receive a community-based maintenance program (intervention) or usual care (control). The primary outcome was 6-min walk distance (6MWD), measured immediately post-PR, 6 months and 12 months later. Secondary outcomes included self-reported functional capacity, health-related quality of life, self-efficacy, program cost, and lower extremity muscle strength. RESULTS: Ninety-seven patients (69 ± 9 years) were enrolled. There was a non-significant trend of an intervention effect on 6MWD over time (ß = 42, 95% CI: 0.06 to 83.93, p = 0.053). There was no significant impact of group on any of the secondary outcomes. Restricting the analysis to those who attended ≥50% of the exercise sessions showed a significant intervention effect for 6MWD (ß = 69.19, 95% CI = 10.16 to 128.22, p = 0.03). The cost of participating in the community maintenance program for the intervention group was $374.77 (SD 142.12) and membership renewal was highest at community centres offering twice weekly, supervised exercise classes. CONCLUSIONS: A post rehabilitation, community-based exercise program, will maintain exercise capacity in people with COPD who attend at least 50% of available sessions over one year. An increased focus on factors that determine adherence would help inform improvements in maintenance program design.

Measurement properties of preference-based measures for economic evaluation in COPD: a systematic review.

PURPOSE: Preference-based measures can provide measurements of health-related quality of life and be utilized for cost-effectiveness analyses of interventions in individuals with chronic obstructive pulmonary disease (COPD). The purpose of this study is to evaluate whether generic preference-based measures are reliable, valid, and responsive in COPD. METHODS: A systematic review was performed using the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) guidelines. Three databases were searched: MEDLINE, EMBASE, and CINAHL. Studies were included if the sample represented individuals with COPD and the aim was to evaluate one or more psychometric properties or the interpretability of generic preference-based measures. RESULTS: Six hundred and sixty-seven abstracts were screened, 65 full-text articles were reviewed and 24 articles met the inclusion criteria. Measures which emerged from the search were the EQ-5D, the SF-6D, the Quality of Well-being scale, the 15D, and the Health Utilities Index 3. Evidence for the test-retest reliability of these measures was limited. Construct validity of the measures was well supported with correlations with generic health profiles being 0.37-0.68, and correlations with COPD-specific health profiles being 0.53-0.75. Evidence for known-groups validity of these measures was poor and data on responsiveness were mixed. CONCLUSION: Generic preference-based measures' sensitivity to change and ability to discriminate between different disease severities in COPD was poorly supported. Future research may consider examining the development of COPD-specific preference-based measures that may allow for a more accurate detection of change and discrimination among disease severities to facilitate cost-effectiveness evaluations.

Balance assessment in people with COPD: An evidence-based guide.

Balance problems and an increased rate and risk of falls are common in people with chronic obstructive pulmonary disease (COPD). Although a balance assessment is now recommended by clinical practice guidelines for pulmonary rehabilitation, specific tests have yet to be suggested. The purpose of this review is to provide an evidence-based synthesis of balance measurement in older adults and in people with COPD, to guide practice in this area. An overview of best practices for assessing balance and fall risk in older adults is provided along with a practical synthesis of evidence to date on common balance measures used in people with COPD such as the Timed Up and Go, Single Leg Stance, Berg Balance, and Mini and Full Balance Evaluation Systems Tests. Finally, two clinical scenarios are described to illustrate the process of evidence-based clinical decision-making with respect to balance assessment in people with COPD. Ultimately, the selection of balance test and its interpretation will depend on the purpose of the assessment, available data on psychometric properties, the patient's individual characteristics, and the resources available to the clinician.

How Should Disability Be Measured in Older Adults? An Analysis from the Boston Rehabilitative Impairment Study of the Elderly.

OBJECTIVES: To determine and compare the predictive validity and responsiveness of the Late-Life Function and Disability Instrument (LLFDI) frequency and limitation dimensions in assessing two critical dimensions of disability: frequency of and limitations in performance of major life roles. DESIGN: Secondary analysis of 2-year follow-up data from the Boston Rehabilitative Impairment Study of the Elderly. SETTING: Primary care. PARTICIPANTS: Community-dwelling older adults (≥65) (n = 430) at risk of mobility decline. MEASUREMENTS: The LLFDI frequency and limitation dimensions, self-rated health, hospitalizations, and emergency department (ED) visits over 2 years. Responsiveness measures included effect size (ES) estimates and minimal detectable change (MDC) scores. RESULTS: The LLFDI frequency dimension predicted low self-rated health (odds ratio (OR) = 0.51, P < .001), hospitalizations (OR = 0.68, P < .001), and ED visits (OR = 0.73, P = .003) over 2 years, whereas the limitation dimension did not. The absolute ES was 0.63 for the frequency dimension and 0.81 for the limitation dimension. The proportion of subjects with a decline greater than or equal to the MDC was 10.6% for the frequency dimension and 14.2% for the limitation dimension. For participants who improved greater than or equal to the MDC, the proportion was 1.7% for the frequency dimension and 15.3% for the limitation dimension. CONCLUSION: Frequency of participation in major life roles was a better predictor of adverse outcomes than perceived limitations, although limitations appeared to be more responsive to meaningful change. These results can be used to guide the selection of the most appropriate metric for measuring disability in geriatric research.

Predictive validity and responsiveness of patient-reported and performance-based measures of function in the Boston RISE study.

BACKGROUND: Patient-reported and performance-based measures (PBMs) are commonly used to measure physical function in studies of older adults. Selection of appropriate measures to address specific research questions is complex and requires knowledge of relevant psychometric properties. The aim of this study was to examine the predictive validity for adverse outcomes and responsiveness of a widely used patient-reported measure, the Late-Life Function and Disability Instrument (LLFDI), compared with PBMs. METHODS: We analyzed 2 years of follow-up data from Boston RISE, a cohort study of 430 primary care patients aged ≥65 years. Logistic and linear regression models were used to examine predictive validity for adverse outcomes and effect size and minimal detectable change scores were computed to examine responsiveness. Performance-based functional measures included the Short Physical Performance Battery, 400-m walk, gait speed, and stair-climb power test. RESULTS: The LLFDI and PBMs showed high predictive validity for poor self-rated health, hospitalizations, and disability. The LLFDI function scale was the only measure that predicted falls. Absolute effect size estimates ranged from 0.54 to 0.64 for the LLFDI and from 0.34 to 0.63 for the PBMs. From baseline to 2 years, the percentage of participants with a change ≥ minimal detectable change was greatest for the LLFDI scales (46-59%) followed by the Short Physical Performance Battery (44%), gait speed (35%), 400-m walk (17%), and stair-climb power test (9%). CONCLUSIONS: The patient-reported LLFDI showed comparable psychometric properties to PBMs. Our findings support the use of the LLFDI as a primary outcome in gerontological research.

Increasing the clinical utility of the BESTest, mini-BESTest, and brief-BESTest: normative values in Canadian adults who are healthy and aged 50 years or older.

BACKGROUND: Balance is a composite ability requiring the integration of multiple systems. The Balance Evaluation Systems Test (BESTest) and 2 abbreviated versions (the Mini-BESTest and the Brief-BESTest) are balance assessment tools that target these systems. To date, no normative data exist for any version of the BESTest. OBJECTIVE: The purpose of this study was to determine the age-related normative scores on the BESTest, Mini-BESTest, and Brief-BESTest for Canadians who are healthy and 50 to 89 years of age. DESIGN: A cross-sectional study design was used. METHODS: Seventy-nine adults who were healthy and aged 50 to 89 years (mean age=68.9 years; 50.6% women) participated. Normative scores were reported by age decade. RESULTS: Mean BESTest scores were 95.7 (95% confidence interval [CI]=94.4-97.1) for adults who were aged 50 to 59 years, 91.4 (95% CI=89.8-93.0) for those who were aged 60 to 69 years, 85.4 (95% CI=82.5-88.2) for those who were aged 70 to 79 years, and 79.4 (95% CI=74.3-84.5) for those who were aged 80 to 89 years. Similar results were obtained for the Mini-BESTest and the Brief-BESTest, and all 3 tests showed statistically significant differences in scores among the age cohorts. LIMITATIONS: Because only adults who were 50 to 89 years of age were tested, there are still no normative data for people outside this age range. Also, the scores presented may not be generalizable to all countries. CONCLUSIONS: These normative data enhance the clinical utility of the BESTest, Mini-BESTest, and Brief-BESTest by providing clinicians with reference points to guide treatment.

A novel approach to long-term respiratory care: results of a community-based post-rehabilitation maintenance program in COPD.

BACKGROUND: Although the short-term benefits of pulmonary rehabilitation (PR) are well established, improvements in exercise tolerance and health status diminish over time. The objectives of this study were to determine the feasibility and within-subject effects of a 1-year community-based maintenance exercise program for patients with COPD following completion of hospital-based PR. METHODS: A single-arm longitudinal study was undertaken. After completion of PR, consecutive patients with COPD were recruited to attend a twice weekly exercise program supervised by fitness consultants at a local community centre. The transition from hospital to the community was facilitated by a case manager. Outcome measurements at baseline (pre-PR), post-PR, 6-months and 1-year included the 6-minute walk test (6MWT) for exercise capacity and the Chronic Respiratory Questionnaire (CRQ) for health-related quality of life. Feasibility was assessed primarily through subject adherence. RESULTS: A total of 29 patients (mean age 66.8 ± 7.8 years, mean FEV1 45.1 ± 18.8 percent predicted) were enrolled in the program. Mean compliance to twice weekly exercise was 70%. No adverse events were reported. Statistically significant and clinically important improvements in the 6MWT and CRQ total and dyspnea domain were observed at 6-months and 1-year after PR compared to baseline (all p < 0.01). CONCLUSIONS: A community-based maintenance exercise program is feasible and can successfully preserve exercise capacity and health-related quality of life following institutionally-based PR in patients with moderate to severe COPD. A more formal evaluation of this approach is warranted.