Changes in disability in older adults with generalized radiographic osteoarthritis: A complex relationship with physical activity.

OBJECTIVE: The aim of the present study was to report on factors associated with changes in disability after 5 years, with a focus on physical activity (PA) in community-dwelling older adults with generalized radiographic osteoarthritis (GROA). METHODS: Assessment of GROA (hand, knee, hip) and disability (Health Assessment Questionnaire) in the Rotterdam Study (cohort RS-1, N = 7,983; with GROA, n = 821). A good outcome at follow-up was defined as improved or mild disability, and a poor outcome as worsened or severe disability. Factors potentially associated with outcome were demographics, joint complaints, other chronic health problems or limitations (body mass index, number of chronic conditions, cognition), and level of different types of PA. Some of these assessments were repeated in between 1997 and 1999 (RS-3), and between 2002 and 2004 (RS-4). RESULTS: A total of 309 older adults with GROA and valid measures on RS-3 and RS-4 showed mild to moderate disability, with minor increases over 5 years (follow-up N = 287 RS-3 to RS-4). PA levels decreased with increasing disability, especially in sport and walking. PA was univariately associated with a better outcome at follow-up but when adjusted for other factors (higher age, having knee pain and stiffness, and having more than two other chronic conditions) was associated with negative changes in general and lower limb disability, although not with upper limb disability. CONCLUSIONS: This was the first study to report that community-dwelling older adults with GROA show moderate levels of disability, and that reduced levels of disability are associated with higher levels of PA, but when adjusted for other confounders this association is lost. Further research is needed to study the complex relationships between PA and other determinants of disability.

The association of pre-operative physical fitness and physical activity with outcome after scheduled major abdominal surgery.

We studied whether reported physical activity and measurements of fitness (hand, leg and inspiration) were associated with postoperative in-hospital mortality, length of stay and discharge destination in 169 patients after major oncological abdominal surgery. In multivariate analysis, adequate activity level (OR 5.5, 95% CI 1.4-21.9) and inspiratory muscle endurance (OR 5.2, 95% CI 1.4-19.1) were independently associated with short-term mortality, whereas conventional factors, such as age and heart disease, were not. Adequate activity level (OR 6.7, 95% CI 1.4-3.0) was also independently associated with discharge destination. The factors that were independently associated with a shorter length of hospital stay were as follows: absence of chronic obstructive pulmonary disease (HR 0.6, 95% CI 0.3-1.1); adequate activity level (HR 0.6, 95% CI 0.4-0.8); and inspiratory muscle strength (HR 0.6, 95% CI 0.5-0.9). For all postoperative outcomes physical activity and fitness significantly improved the predictive value compared with known risk factors, such as age and comorbidities. We conclude that pre-operative questionnaires of physical activity and measurements of fitness contribute to the prediction of postoperative outcomes.

Exploring the public health impact of an intensive exercise program for patients with rheumatoid arthritis: a dissemination and implementation study.

OBJECTIVE: To evaluate the implementation of an intensive group exercise program in patients with rheumatoid arthritis (RA). METHODS: In 4 regions in The Netherlands, the Rheumatoid Arthritis Patients In Training exercise program was implemented on a limited scale. Evaluation using the RE-AIM model included: Reach, the proportion of the target population participating; Efficacy, effects on muscle strength, aerobic capacity, functional ability, and psychological functioning; Adoption, program adoption by stakeholders; Implementation, intervention quality (quality audits); and Maintenance, stakeholders' willingness to continue the program in the future. RESULTS: Twenty-five physical therapists from 14 practices were trained to provide the program. In total, 150 RA patients were recruited (by estimation, 2% of the target population). Of the 81 patients who had finished the 12-month intervention and were available for followup directly after the intervention, 62 patients provided clinical data. Muscle strength improved significantly, whereas aerobic capacity, functional ability, psychological functioning, and disease activity did not change. All 9 informed local patient organizations facilitated patient recruitment, and 35 of 51 rheumatologists involved referred one or more patients. All 10 approached health insurance companies funded the program for 12 months. The quality audits showed sufficient quality in 9 of 12 practices. All of the providers of the program were willing to provide the program in the future, whereas future reimbursement by health insurance companies remained unclear. CONCLUSION: The implementation of an intensive exercise program for RA patients on a limited scale can be considered successful regarding its reach, adoption, and implementation. The limited effectiveness and the limited data regarding maintenance warrant additional research.

Walking or vitamin B for cognition in older adults with mild cognitive impairment? A randomised controlled trial.

OBJECTIVE: To examine the effects of aerobic exercise or vitamin B supplementation on cognitive function in older adults with mild cognitive impairment (MCI). DESIGN: Randomised placebo-controlled trial. SETTING: General community. PARTICIPANTS: Community-dwelling adults aged 70-80 with MCI. Interventions : The 152 participants were randomly assigned to two INTERVENTIONS: (1) a twice-weekly, group-based, moderate-intensity walking programme (WP, n = 77) or a low-intensity placebo activity programme (n = 75) for one year; and (2) daily vitamin pill containing 5 mg folic acid, 0.4 mg vitamin B-12, 50 mg vitamin B-6 (FA/B12/B6, n = 78) or placebo pill (n = 74) for one year. OUTCOME MEASURES: Cognitive function, measured with neuropsychological tests at baseline and after six and 12 months. RESULTS: Median session attendance at the exercise programmes (25th-75th percentile) was 63% (2%-81%) and median compliance with taking pills (25th-75th percentile) was 100% (99%-100%). Gender was an effect modifier. Intention-to-treat analysis revealed no main intervention effect for either intervention. In women in the WP, attention (Stroop combination task) improved by 0.3 seconds (p = 0.04) and memory (auditory verbal learning test) by 0.04 words (p = 0.06) with each percentage increase in session attendance. In men attending at least 75% of the sessions, the WP improved memory (beta 1.5 (95% CI: 0.1 to 3.0) words). CONCLUSION: The walking programme and/or FA/B12/B6 supplementation were not effective in improving cognition within one year. The walking programme, however, was efficacious in improving memory in men and memory and attention in women with better adherence. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number Register, 19227688, http://www.controlled-trials.com/isrctn/

[More exercise for seniors: report of program evaluation]. / Meer bewegen voor ouderen gymnastiek: verslag van een evaluatiestudie.

Since 1980, More Exercise for Seniors (MBvO in Dutch) has provided a number of special physical activities for the elderly. The aim is to improve social participation and integration, and to prevent a need for care. Despite the fact that MBvO has been active for more than 25 years, and weekly 300,000 people participate in gymnastics, swimming, dancing, etc, no effect on fitness and health has been proven to date. The study was carried out in two regions: Drenthe and Zuid-Holland. Using the GALM (Groningen Active Living Model) method, 4600 independently living people aged 65 years and older were asked to participate in a motor fitness test. Of the 721 people who participated, 386 (the least fit) were invited to take part in the study. They were than randomly divided into an experimental and a control group. The experimental group did gymnastics once or twice a week. The control group received a health educational program. Assessments were carried out at pretest and posttest (10 weeks). In the groups offered MBvO gymnastics once a week, no effects were found on subjective health, physical performance or quality of life and only minor effects on physical fitness. In the groups offered MBvO gymnastics twice a week, some beneficial quality of life effects were found in the least physically active people at baseline. It is recommended that the frequency and intensity of the regular MBvO gymnastics should be increased, to emphasize the importance of health education, and that relatively inactive and older individuals (70+) should be recruited.

An implementation study of two evidence-based exercise and health education programmes for older adults with osteoarthritis of the knee and hip.

Implementation studies are recommended to assess the feasibility and effectiveness in real-life of programmes which have been tested in randomized controlled trials (RCTs). We report on an implementation study of two evidence-based exercise and health education programmes for older adults with osteoarthritis (OA) of the knee or hip. Three types of primary health-care providers (n = 18) delivered the OA Knee programme (n = 20) and the OA Hip programme (n = 20), supported by programme manuals and implementation guidelines, in four regions. The outcome measures were pain and mobility. The Knee programme had OA knowledge and self-efficacy as additional outcome measures. Differences in outcome measures and background variables of participants were assessed between the RCTs and the implementation study. Positive effects (P < 0.05) were found for OA knowledge, pain and self-efficacy in the Knee programme (n = 157), and for pain in the Hip programme (n = 132). No effect was found for mobility. Effect sizes of the RCTs and the present study were comparable. Background variables did not explain the variance in the outcome measures. The outcomes of the previous RCTs and the implementation study were comparable, and indicated the ecological validity of the two programmes. The implications for nationwide dissemination and implementation in The Netherlands are discussed.

Once a week is not enough: effects of a widely implemented group based exercise programme for older adults; a randomised controlled trial.

OBJECTIVES: To determine the effects of gymnastics on the health related quality of life (HRQoL) and functional status of independently living people, aged 65 to 80 years. Gymnastics formed part of the More Exercise for Seniors (MBvO in Dutch) programme, a group based exercise programme for older adults in the Netherlands. It has been widely implemented since 1980. DESIGN: Randomised controlled trial with pretest and post-test measurements. INTERVENTION: The exercise programme given by experienced instructors lasted 10 weeks and was given weekly (MBvO1; n = 125, six groups) or twice weekly (MBvO2; n = 68, six groups). The control group (n = 193) was offered a health education programme. SETTING: Community dwelling of older people, with a comparatively low level of fitness as assessed with the Groningen Fitness test for the Elderly. RESULTS: No significant effects were found on the HRQoL (Vitality Plus Scale, TAAQoL, and RAND-36) and the functional status (Physical Performance Test and the Groningen Activity Restriction Scale). The MBvO2 group, with a low level of physical activity at baseline, showed the only improvement found on the Vitality Plus Scale (F = 4.53; p = 0.01). CONCLUSIONS: MBvO gymnastics once a week did not provide benefits in HRQoL and functional status after 10 weeks. However, participants with a low level of physical activity may benefit from MBvO gymnastics if they participate twice a week. To improve the health of the general public, sedentary older adults should be recruited and encouraged to combine MBvO with the health enhancing physical activity guidelines.

Assessing comparability of dressing disability in different countries by response conversion.

BACKGROUND: Comparability of health data is a major challenge within the context of the Health Monitoring Programme of the European Commission. A common problem in surveys is that many variations of essentially the same question exist. METHODS: Response conversion is a new method for improving comparability by scaling the data onto a common scale. Comparisons between member states can then be made in terms of the common scale. A first step is the construction of a conversion key. This is a relatively complex activity, but needs to be done only once. The second step is the actual data transformation. This is simple, and can be repeatedly done on a routine basis as new information arrives. Construction of the key is only possible if enough overlapping information can be found. RESULTS: The method is illustrated for dressing disability from five European countries. Differences occur between countries, between sexes and between age groups. These were similar in magnitude. CONCLUSION: Response conversion is a new method for enhancing comparability among existing data. Conversion can only be done if a key is available. More work is needed to establish the technique. Future implications within the Health Monitoring Programme are discussed.

Promotion of health and physical activity improves the mental health of elderly immigrants: results of a group randomised controlled trial among Turkish immigrants in the Netherlands aged 45 and over.

OBJECTIVES: Older immigrants from non-industrialised countries are a growing group, they have comparatively many health problems and are often hard to reach through health promotion and other preventive services. The aim of this study was to assess the effect of a short health education and physical exercise programme on the health and the physical activity of Turkish first generation elderly immigrants. DESIGN: Randomised controlled trial. SETTING: Welfare services in six Dutch cities. PARTICIPANTS: 126 people born in Turkey and aged 45 years and over, of whom 92 completed the trial. INTERVENTION: Eight, two hour sessions consisting of health education and exercises. Topics in health education focused on means to maintain a good health. Education was adapted to the culture and knowledge of older Turks and offered by a Turkish peer educator, in Turkish. MAIN OUTCOME MEASURES: Physical and mental wellbeing, and mental health based on the SF-12/36; knowledge on health and disease; physical activity. RESULTS: Participants were highly disadvantaged; 52% had not completed primary school and 49% had considerable problems in speaking Dutch. Participants in the intervention group showed an improvement in mental health (effect size: 0.38 SD (95% confidence intervals 0.03 to 0.73), p=0.03); the oldest subgroup also in mental wellbeing (effect size 0.75 SD (0.22 to 1.28), p=0.01). No improvements were seen in physical wellbeing and activity, nor in knowledge. CONCLUSIONS: Health education and physical exercise improve the mental state of deprived immigrants. Painstaking cultural adaptations to contents and method of delivery are essential to reach this effect.

[Health education and exercise stimulation for older people: development and evaluation of the program "Healthy and Vital"]. / Gezondheidsvoorlichting en bewegingsstimulering voor ouderen: ontwikkeling en evaluatie van het programma "Gezond & Vitaal".

In order to promote health in people of 65 years and older, TNO Prevention and Health developed, evaluated, and implemented "Healthy & Vital" (also known as "Ageing Well and Healthily"). Healthy & Vital consists of six sessions of health education and low-intensity exercises. This paper reports on the theoretical basis of the intervention, the methods and results of a Randomised Controlled Trial (n = 50), and a Community Intervention Trial (in 8 municipalities, n = 448). A brief report is given of the implementation study. Healthy & Vital had a number of positive physiological effects, such as a decrease in blood pressure (effect size -0.55), the Body Mass Index (effect 0.62), and the level of blood glucose (1.00), especially in women and in elderly people who are less active physically. Participants' understanding of health and illness increased significantly (effect 0.78). Due to ceiling effects only a few effects on subjective general health were found, and they disappeared after 6 months. A positive effect on feelings of loneliness remained even after 6 months (p < 0.1). The most important effect of Healthy & Vital was the increase in physical activity, especially in the least active elderly (p < 0.001). Twenty-five per cent of the participants continued activities with More Exercise for Seniors, 28% were still considering this, and 19% continued at home with the exercises they had learnt. Currently, Healthy & Vital is being implemented nationally by the Local Policy for the Elderly Knowledge Centre (www.lokoud.nl).

Development and validation of the Observation List for early signs of Dementia (OLD).

OBJECTIVE: Development and validation of a short Observation List of possible early signs of Dementia (OLD) for use in general practice. DESIGN: Stepwise development using reviews of publications and expert consensus. Field study for evaluation of reliability. Validation study (interviews, family forms) using existing valid and reliable measures. Use of data reduction techniques to construct a short version. Setting of field study Twenty-two GPs in 19 Dutch practices. PARTICIPANTS: The first two patients seen on 15 working days (n = 470) were observed. Inclusion: age > 75, without a known diagnosis of dementia. Exclusion: psychiatric treatment, severe depression, acute illness with confusion. Division of patients into three groups with no, intermediate, and the most signs (total of interviewed patients, n = 60; family forms, n = 39). Outcome measures Reliability (Cronbach's alpha and factor-analysis). Convergent validity using the Cognitive Screening Test (CST), the Word Learning Test (WLT, total and retention), the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), the Groningen Activities Restriction Scale (GARS), and an IADL scale. Discriminant validity using the geriatric depression scale (GDS). Construct validity using a Principal Component Analysis (PRINCALS). Incremental validity using the intuitive opinion of the GP (McNemar test). RESULTS: Reliability in the total group 0.88, first factor explained variance 42.5%. Convergent validity (two-way ANOVA) results: CST (p = 0.00), WLT-total (p = 0.001), WLT retention (p = 0.00), IQCODE (p = 0.09). No statistically significant differences for GARS and IADL. GDS (p = 0.30) not different. PRINCALS first factor explained 48% of variance. The OLD added to the GP opinion (McNemar p = 0.00). Reliability short version 0.89 (interviewed group), 0.86 (total group). CONCLUSIONS: The OLD is a valid and reliable method to detect early signs of dementia in general practice that can indicate when it may be useful to employ existing screening instruments.

[Indicators of early Alzheimer dementia in family practice. Development and validation of the Observation List of Early Symptoms of Dementia (OLD)]. / Signalering van beginnende Alzheimer-dementie in de huisartspraktijk. Ontwikkeling en validering van de Observatie Lijst voor vroege symptomen van Dementie (OLD).

UNLABELLED: Aim of the study was the development and validation of a short observation list of possible early signs of dementia (OLD) for use in general practice. A stepwise development was carried out using reviews of publications and expert consensus. Experimental observations were carried out by 22 general practitioners in 19 Dutch practices. A field study (with interviews and family forms) was conducted out afterwards, to evaluate reliability and validity. Data reduction techniques were used to construct a short version. The first two patients seen on 15 working days (N = 470) were observed. INCLUSION CRITERIA: age > 75, without a known diagnosis of dementia. Exclusion: psychiatric treatment, severe depression, acute illness with confusion. The patients were divided into three groups with no, intermediate, and the most signs (total of interviewed patients n = 60; family forms n = 39). Cronbach's alpha and factor-analysis were used to evaluate the reliability. The Cognitive Screening Test (CST), the Word Learning Test (WLT; total and retention), the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), the Groningen Activities Restriction Scale (GARS), and an IADL scale were used to evaluate convergent validity. The Geriatric Depression Scale (GDS) was used to evaluate discriminant validity. Construct validity was evaluated using PRINCALS. Incremental validity was evaluated using the intuitive opinion of the GP (McNemar test). The reliability in the total group was 0.88, the first factor explained 42.5% of the variance. Convergent validity (2-side ANOVA) results: CST (p = 0.00), WLT-total (p = 0.001), WLT retention (p = 0.00), IQCODE (p = 0.09). No statistically significant differences were found for GARS and IADL. The GDS (p = 0.30) showed no difference. The first factor of PRINCALS explained 48% of the variance. The OLD added to the GP opinion (McNemar p = 0.00). Reliability of the short version (12 items) was 0.89 (interviewed group), and 0.86 (total group). The conclusion is that the OLD is a valid and reliable method to detect early signs of dementia in general practice. (Partly adapted from: Hopman-Rock M, Tak ECPM, Staats PGM. Development and validation of the Observation List for early signs of Dementia (OLD). Int J Geriatr Psychiatry 2001 (in press)).

The onset of generalized osteoarthritis in older women: a qualitative approach.

OBJECTIVE: This qualitative study aims to investigate which factors are possibly associated with the onset of generalized osteoarthritis (OA) in older women. METHODS: The study population was recruited from participants of a group course, "Coping With Osteoarthritis of the Hip or Knee." Twenty-three women with generalized OA were identified, 20 of whom participated in a semistructured interview at home. All data were self-reported by the subjects. RESULTS: Hereditary factors were present in 17 women. Metabolic factors (such as impairments in carbohydrate and lipid metabolism, diabetes, etc.) were not prevalent. Twelve women thought that certain diets influenced their pain symptoms. Five women spontaneously mentioned their health status during the Second World War as a cause of their OA. Four considered too much stress as being a cause, and in 13 women symptoms started after a period of stressful life events or depression. CONCLUSION: According to the respondents, depression, stress, and diets are associated with the onset and worsening of their generalized OA. Heredity and a low health status at a vulnerable age may also be important. These findings could generate new hypotheses that can be tested in future quantitative studies.

Revision of the ICIDH Severity of Disabilities Scale by data linking and item response theory.

The Severity of Disabilities Scale (SDS) of the ICIDH reflects the degree to which an individual's ability to perform a certain activity is restricted. This paper describes the application of two models from item response theory (IRT), the graded response model and the partial credit model, in order to derive a tentative proposal for a revised SDS. The key ingredient of the approach is to scale existing disability items obtained in different studies on a common scale by exploiting the overlap. Both IRT models are fitted to a linked data set containing items for measuring walking disability. Based on these solutions, a tentative SDS is constructed. The paper concludes with a discussion of the implications, limitations and advantages of the approach.

The effects of a health educational and exercise program for older adults with osteoarthritis for the hip or knee.

OBJECTIVE: Evaluation of a self-management program for patients with osteoarthritis (OA) of the hip or knee. The program, which consisted of 6 weekly sessions of 2 hours, included health education by a peer and physical exercises taught by a physical therapist. METHODS: Randomized controlled trial. Inclusion criteria were diagnosis of OA of the hip or knee according to ACR clinical and radiographic criteria and age 55 to 75 years. EXCLUSION CRITERIA: on waiting list for joint replacement. There were pretest, posttest, and followup (6 months) assessments. The experimental group consisted of 56 patients, the control group 49. Outcome variables were pain, quality of life, activity restrictions, knowledge about OA, self-efficacy, body mass index (BMI), and mobility measures. Attention was also paid to effects on health care utilization and lifestyle behavior. RESULTS: Significant MANOVA group x time effects (p < 0.05, one-sided) were found for pain, quality of life, strength of the left M. quadriceps, knowledge, self-efficacy, BMI, physically active lifestyle, and visits to the physical therapist. Most effects were moderate at posttest assessment and smaller at followup. No effects were found for range of motion and functional tasks. CONCLUSION: The program was reasonably effective, but more attention should be paid to proactive followup interventions and to the selection of participants.

Polytomous Rasch analysis as a tool for revision of the severity of disability code of the ICIDH.

PURPOSE: To develop a preliminary proposal for the revision of the severity code of the ICIDH-D 1980. METHOD: Quantitative analysis (polytomous Rasch analysis) of linked existing data sources including items about walking and dressing disability. RESULTS: The Rasch analysis provided estimates of threshold parameters for walking and dressing item categories. Factor analysis showed that more than one dimension was present, but that the first factor could definitely be interpreted as 'disability'. The reliability of the solutions was satisfactory (0.88 for walking and 0.91 for dressing). CONCLUSION: Based on the results, tentatively a new severity code is proposed with more distinct categories of 'difficulty' than the existing code, and the use of technical aids and personal assistance in the higher ranks. The Rasch method could be a useful tool for calibrating and measuring disability, as well as for converting existing disability data into a new uniform severity of disability code.

The effects of a psychomotor activation programme for use in groups of cognitively impaired people in homes for the elderly.

OBJECTIVES: To test the effects of the Psychomotor Activation Programme (PAP) on the behaviour and cognition of demented elderly people. DESIGN: Randomized controlled trial with an experimental group and a control group. Post-test after 6 months. SETTING: Group care projects for demented elderly people living in 11 different homes for the elderly in The Netherlands. PARTICIPANTS: One hundred and thirty-four subjects entered the study (72 in the experimental group and 62 in the control group), 42 of whom dropped out (27 in the experimental group and 15 in the control group). MEASUREMENTS: Individual behaviour and group behaviour were scored using two Dutch scales (BIP and SIPO respectively) developed and validated for use in psychogeriatric populations. Cognition was measured with the short and the long versions of the Cognitive Screening Test (CST-14 and CST-20). Disability was measured with the Barthel Index. Medicine use, falls, other accidents and life events were registered. RESULTS: The PAP had a beneficial effect on cognition (CST-14, F = 2.63, p < or = 0.05, effect size 0.4) (CST-20, F = 3.77, p < or = 0.05, effect size 0.5) and increased positive group behaviour in participants with relatively mild cognitive problems (SIPO, F = 4.46 p < or = 0.05). CONCLUSIONS: The PAP stabilizes cognitive performance and has some beneficial effects on behaviour. Positive findings were supported by a simultaneously conducted process evaluation.

Coping with pain in the hip or knee in relation to physical disability in community-living elderly people.

OBJECTIVE: To investigate the use of pain coping strategies by community-living older people with pain in the hip or knee and the mediating role of coping with pain in the relationship between the chronicity of pain and physical disability. METHODS: A group of 157 people with pain "in the last month" was identified. Coping with pain was assessed with the Pain Coping Inventory, physical disability with the Sickness Impact Profile, and household and sport activities with a validated structured interview method. RESULTS: People with chronic pain used relatively more "resting," and "reducing demands" as pain coping strategies. Pain chronicity made a significant contribution to physical disability; however, when corrected for other variables in a regression model, no significant partial correlation was found. CONCLUSION: We conclude that pain coping has a mediating role in the relationship between pain chronicity and physical disability. Less use of "resting" and a physically active lifestyle are independently associated with less physical disability.