The Case for Developing a Movement System Framework for Older Adults.

Leaders and scholars from multiple academies of the American Physical Therapy Association are developing and defining movement system diagnoses to guide practice. However, there is no consensus on the need for or content of such frameworks. This Perspective describes current thought about movement system diagnoses in physical therapy and summarizes the work of the Academy of Geriatrics (APTA Geriatrics) Movement System Diagnosis Task Force (GMS-TF) as it contributes to the movement system diagnosis discussion within the profession. Initially convened to define movement system diagnostic labels unique to older adults, the GMS-TF's developmental process identified the need for a clearer diagnostic framework onto which specific diagnoses will later be added. Although The World Health Organization International Classification of Functioning, Disability and Health model is a strong foundation for the patient-client management model, the GMS-TF proposes formal incorporation of the Geriatric 5Ms (mobility, medications, memory, multi-complexity, and "what matters most") into a movement system framework for older adults. The GMS-TF concurs with the APTA Academy of Neurology Movement System Task Force proposal that observation and analysis of key functional tasks are the foundation of any examination of older adults. The GMS-TF suggests adding several additional movement tasks that are important for older adults. The GMS-TF believes that this strategy highlights the health care needs of older adults and prioritizes physical therapist care for older adults with complex needs. This Perspective is the foundation for a future movement system diagnosis model for older adults that will complement and facilitate the development of models of care to be applied across the lifespan.

Determining Risk of Falls in Community Dwelling Older Adults: A Systematic Review and Meta-analysis Using Posttest Probability.

BACKGROUND: Falls and their consequences are significant concerns for older adults, caregivers, and health care providers. Identification of fall risk is crucial for appropriate referral to preventive interventions. Falls are multifactorial; no single measure is an accurate diagnostic tool. There is limited information on which history question, self-report measure, or performance-based measure, or combination of measures, best predicts future falls. PURPOSE: First, to evaluate the predictive ability of history questions, self-report measures, and performance-based measures for assessing fall risk of community-dwelling older adults by calculating and comparing posttest probability (PoTP) values for individual test/measures. Second, to evaluate usefulness of cumulative PoTP for measures in combination. DATA SOURCES: To be included, a study must have used fall status as an outcome or classification variable, have a sample size of at least 30 ambulatory community-living older adults (≥65 years), and track falls occurrence for a minimum of 6 months. Studies in acute or long-term care settings, as well as those including participants with significant cognitive or neuromuscular conditions related to increased fall risk, were excluded. Searches of Medline/PubMED and Cumulative Index of Nursing and Allied Health (CINAHL) from January 1990 through September 2013 identified 2294 abstracts concerned with fall risk assessment in community-dwelling older adults. STUDY SELECTION: Because the number of prospective studies of fall risk assessment was limited, retrospective studies that classified participants (faller/nonfallers) were also included. Ninety-five full-text articles met inclusion criteria; 59 contained necessary data for calculation of PoTP. The Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS) was used to assess each study's methodological quality. DATA EXTRACTION: Study design and QUADAS score determined the level of evidence. Data for calculation of sensitivity (Sn), specificity (Sp), likelihood ratios (LR), and PoTP values were available for 21 of 46 measures used as search terms. An additional 73 history questions, self-report measures, and performance-based measures were used in included articles; PoTP values could be calculated for 35. DATA SYNTHESIS: Evidence tables including PoTP values were constructed for 15 history questions, 15 self-report measures, and 26 performance-based measures. Recommendations for clinical practice were based on consensus. LIMITATIONS: Variations in study quality, procedures, and statistical analyses challenged data extraction, interpretation, and synthesis. There was insufficient data for calculation of PoTP values for 63 of 119 tests. CONCLUSIONS: No single test/measure demonstrated strong PoTP values. Five history questions, 2 self-report measures, and 5 performance-based measures may have clinical usefulness in assessing risk of falling on the basis of cumulative PoTP. Berg Balance Scale score (≤50 points), Timed Up and Go times (≥12 seconds), and 5 times sit-to-stand times (≥12) seconds are currently the most evidence-supported functional measures to determine individual risk of future falls. Shortfalls identified during review will direct researchers to address knowledge gaps.

Are scores on the physical performance test useful in determination of risk of future falls in individuals with dementia?

BACKGROUND AND PURPOSE: Presence of dementia influences postural control and increases fall risk. The 7-item physical performance test (PPT) is a valid measure of balance in older adults; however, its validity has not been established in people with dementia. The purpose of this research was to establish predictive validity of the PPT for falls in people with dementia. METHODS: Subjects with dementia (N=34, mean MMSE score 18.4 + 3.3) were tested with the PPT and then followed for four months for fall occurrences. DATA ANALYSIS: A stepwise logistic regression (variables of age, previous history of a fall, and PPT score) determined predictors of a fall. Sensitivity, specificity, and likelihood ratios for each of the significant measures were calculated. RESULTS: Twelve subjects (35%) reported at least one fall in the four months. History of a fall in the previous six months was the only significant predictor of a subsequent fall (p=.044), increasing the odds by almost five times. Calculated sensitivity and specificity for history of a fall were 58% and 77% respectively and positive and negative likelihood ratios were 2.52 and .58 respectively. DISCUSSION: A fall in the previous six months was the strongest predictor of a fall in the subsequent four months in people with dementia. Score on the PPT was not a significant predictor of falls. Further research is warranted, however, since 8 of the 13 subjects falsely identified as a faller by their PPT score (false positives) had other strong indicators of postural control dysfunction.

Impact of participation in a wellness program on functional status and falls among aging adults in an assisted living setting.

PROBLEM: Aging adults residing in assisted living facilities are vulnerable to the effects of cumulative chronic illness and increasingly sedentary lifestyle, both contributing to risk of functional decline over time. Participation in regular exercise appears to preserve functional status and may minimize the rate of functional decline. PURPOSE: This quasi-experimental study evaluated the longitudinal impact of regular participation in a wellness exercise program on functional status of residents in assisted living. METHODS: Thirty-six aging adults participating in a multimodal wellness program were evaluated on enrollment and after 12 months of participation. Cognitive status (Mini-Mental State Examination score), postural control/fall risk (Berg Balance Scale score), and cardiovascular endurance/mobility (6-Minute Walk Test distance) were examined on enrollment and at annual reassessment. Falls over 12 months were determined by tracking annual reported incidence of falls. Subjects were classified as "regular" or "nonregular" exercisers on the basis of participation frequency and adherence. Chi-square analysis and analysis of variance were used to screen for initial differences between groups. Repeated-measures analysis of variance evaluated differences in cognitive status, falls, and functional measures between groups at annual reassessment. RESULTS: Mean age (SD) of participants was 85.5 (6.3) years (range = 72-96 years). There were no differences between groups at the time of enrollment. At annual reassessment, regular exercisers demonstrated better preservation of functional status and a lower rate of falling than nonregular exercisers. CONCLUSION: Regular participation in an individualized wellness program as little as twice weekly for 9 of 12 months provides protection against functional decline and risk of falls in older adults in assisted living settings.

Spatial and temporal parameters of self-selected and fast walking speeds in healthy community-living adults aged 72-98 years.

PURPOSE: There is limited data about typical performance for spatial and temporal measures of self-selected walking speed (SSWS) and fast walking speeds (FWS) for healthy adults older than 75 years. This study reports both velocity and spatial and temporal characteristics of walking by age group and gender for 118 community-living adults between the ages of 72 and 98 years, mean age 84.8 (5.3) years, participating in a functional assessment clinic held at their continuing care retirement community. METHODS: Three trials of SSWS and 3 trials of FWS were captured using the GAITRite system (CIR Systems, Inc., Havertown, Pennsylvania). Velocity, normalized velocity, and other spatial and temporal parameters were calculated by GAITRite software. Independent ttests were used to evaluate differences by age and gender in demographic and anthropometric characteristics, and vital signs. Mean of 3 trials was used to develop performance values by age group and gender. Analysis of variance with appropriate post hoc testing was used to identify differences in gait characteristics by age and gender. RESULTS: There were no differences in anthropomorphic or vital signs by age group; men where taller and heavier as would be expected. There was a consistent age effect for both SSWS and FWS; gait velocity decreased as age increased, with significant differences between all decades of age. There was a significant gender effect, with men walking faster than women at SSWS and FWS. Even after normalizing SSWS and FWS to leg length, men walked faster than females. CONCLUSION: Data reported in this study of generally healthy older adults can be used by rehabilitation professionals to develop goals for functional walking speed and determine readiness for discharge for patients intending to return to community-living settings following their rehabilitation.