DIETARY HABITS AND FUNCTIONAL LIMITATION OF OLDER BRAZILIAN ADULTS: EVIDENCE FROM THE BRAZILIAN NATIONAL HEALTH SURVEY (2013)

E. Alves Valle¹, J. Vaz de Melo Mambrini¹, S. Viana Peixoto^1,2, D. Carvalho Malta², C. de Oliveira³, M.F. Lima-Costa¹

1. Oswaldo Cruz Foundation, René Rachou Research Centre, Belo Horizonte-MG, Brazil; 2. Federal University of Minas Gerais, School of Nursing, Belo Horizonte-MG, Brazil; 3. Department of Epidemiology & Public Health, University College London, London, UK

Corresponding Author: E. Alves Valle, CPQRR/Fiocruz Belo Horizonte, Av. Augusto de Lima, 1715 – Barro Preto, Belo Horizonte – MG, 30190-002, Brazil, +55 31 3349-7700, estevaovalle@gmail.com

J Aging Res Clin Practice 2016;inpress
Published online August 25, 2016, http://dx.doi.org/10.14283/jarcp.2016.112

Abstract

Abstract: Objective: To compare the consumption of selected healthy and unhealthy food groups among elderly Brazilians with daily living activity limitations relative to those with no limitations. Design: Cross-sectional analyses of a nationally representative survey. Setting: The Brazilian National Health Survey, conducted in 2013. Subjects: 11,177 Brazilians aged 60 and over. Results: The prevalence of daily living limitations was 29% (95% CI 27.6,30.5). The consumption of daily meat, beans on a regular basis, and recommended fruit and vegetables intake were 67.1% (95% CI 66.5,68.7), 71.3% (95% CI 69.9,72.8) and 37.3% (95% CI 35.6,39.9), respectively. Compared to those without functional limitation, the consumption of these three food groups was significantly lower among those older adults with functional limitation (Prevalence Ratio = 0.89, 95% CI 0.80,0.98; 0.90, 95% CI 0.82,0.99 and PR 0.86, 95% CI, 0.76,0.96, respectively), independently of age, sex, marital status, living arrangements and education. Level of education showed a strong positive association with fruit and vegetable consumption, and a negative association with bean consumption, a staple diet in Brazil. Conclusions: Our findings highlight the need for public health policies to increase consumption healthy food consumption among those older adults with functional limitations, especially fruit and vegetable intake among those who have low education levels.

Key words: Older adults, nutrition, activity of daily living, disability, healthy ageing, national health survey, Brazil.

Introduction

Nutrition among older adults is a significant public health issue in middle income countries overwhelmed with the rapid demographic ageing (1-3). Furthermore, this scenario generates great concern among policy makers because of the burden of disability in old age. There is evidence that a diet rich in vegetables, fruit, fish, nuts and wine is associated with more disability free days, compared to a diet rich in fast food, fried foods, sweets and fizzy drinks (2). A healthy diet is also associated with better cognition and mental health (3). However, physical, mental and financial barriers experienced by people with disabilities may limit their access to a healthier diet (4). A recent study, based on a nationally representative sample of US adults, showed that people with disabilities are less likely to meet recommended levels of saturated fat, fiber, vitamins A and C, calcium and potassium intakes compared to those without disability (4). These findings highlight the need for further research to investigate the association between poorer diet and disability in different countries and cultures.
Brazil has the world’s fifth largest population and has experienced considerable economic growth over the last decades. As a rapidly ageing middle-income country, social policy development for the elderly is of paramount importance (5, 6). From a nutritional perspective, the prevalence of obesity among Brazilians has increased, while the prevalence of undernutrition has an impressive decline (6). Recently, the Ministry of Health developed a guideline to promote healthy diet, as part of the national strategy for the control of non-communicable diseases and associated risk factors (7). As part of the public national health system (in Portuguese, “Sistema Único de Saúde”), Brazil has a national policy for the elderly, which considers the importance of individual functional status (5). No previous study has compared nutritional patterns between Brazilians with and without disabilities, an essential issue to guide health policies for the elderly.
In the present study, we used data from the most recent Brazilian National Health Survey (8) to describe the dietary habits of older Brazilians, to compare the consumption of selected healthy and unhealthy food groups between those with and without functional limitations and, finally, to identify sociodemographic factors associated to a lower consumption of certain food groups among those individuals with functional limitations.

Methods

The Brazilian National Health Survey (PNS)

Data are derived from the National Health Survey (“Pesquisa Nacional de Saúde”) (8), a nationally representative household survey conducted by the Brazilian Institute of Geography and Statistics (IBGE) and Ministry of Health in 2013. The survey employs a complex sampling design. The primary sampling units are census tracts based on the 2010 census and randomly selected from the IBGE national master sampling plan. Within each census tract, households were randomly selected. Within selected households, a randomly selected respondent aged 18 or over was invited to take part in the study. The final sample size of persons aged 18 years and over was 62,986 (8). All survey participants aged 60 years and older were selected for this analysis.

Functional limitation

Physical functioning limitation was defined as reporting having any difficulty in one or more of the following ten basic (ADL) and/or instrumental activities of daily living (IADL): dressing, walking across a room, bathing or showering, eating, getting in or out of bed, using the toilet, going outside the house using a transportation, managing medications, shopping and managing finances.

Dietary habits

Dietary pattern was assessed by daily or weekly frequency consumption of certain healthy and unhealthy food groups. The following groups, with definitions used, were: regular fish intake (in one or more days per week); regular intake of beans (five or more days per week); recommended fruit and vegetable intake (five or more daily portions, five or more days per week, including wholesome food, in salads or juices); red meat or chicken with visible fat (once or more times per week); full fat milk (any weekly frequency); regular consumption of sweets (five or more days a week); regular ingestion of fizzy drinks or artificial juices (five or more days a week) and high levels of salt (according respondent’s self-perception).In addition, the daily meat consumption (beef, pork and/or chicken) was measured since it is an important marker of protein intake in older adults (9).

Sociodemographic characteristics

Sociodemographic characteristics include age group (60-64, 65-74, 75 and older), sex, marital status (married, divorced/single and widow), number of residents within the household (live alone, two, three or more) and educational attainment. Educational attainment was categorized into: less than four years of schooling, five to eight years of schooling, nine to eleven years of schooling, and 12 years or more.

Statistical analysis

Descriptive analyses were based on prevalence and their respective 95% confidence intervals. In the unadjusted analyses, Pearson Chi Squared test was used to assess the significance of differences between the sociodemographic variables and the dietary patterns of older adults with and without functional limitations. Multivariate analyses, investigating the association between dietary patterns and functional limitations, were performed using prevalence ratios and their 95% confidence intervals through Poisson regression models (10). This was also the statistical approach used to examine the associations between sociodemographic characteristics and daily meat intake, recommended daily intake of fruit and vegetables and regular ingestion of beans of older adults with and without functional limitations. The estimated prevalence ratios from the Poisson regression models were adjusted simultaneously by age, sex, educational attainment, marital status and number of residents within the household. All analyses were performed using Stata version 13.0 and results incorporate appropriate procedures to control for weights and the complex PNS sample design (11).

Ethical approval

The National Health Survey was approved by the National Commission of Ethics in Research on Human Beings (in Portuguese, “Comissão Nacional de Ética em Pesquisa”), of the Ministry of Health, (Process number 328.159 of June 2013). All participants signed a consent form.

Results

The present analysis was based on 11,177 survey participants aged 60 years and over. 3,340 (29.0%; 95% CI: 27.6-30.5%) reported some functional limitation. Table 1 presents descriptive statistics for the sample. Overall, participants predominantly aged between 65 and 74, were female, married, residents in households with 3 or more residents and had five to eight years of schooling. The prevalence of women with functional limitation was significantly higher compared to those without functional limitations (62.4% versus 53.9%). Statistically significant differences (p<0.05) between those with functional limitation compared to those without were observed for oldest age (46.5% vs. 16.7%aged 75 and older, respectively), widowed (39% vs 21.5%) and those with educational attainment less than four years of schooling (47.7% vs 25.7%).

Table 1
Sociodemographic characteristics of the sample of older Brazilians, and by functional limitation status (The Brazilian National Health Survey, 2013)

1. At least one difficulty in the following ten activities: dressing, walking across a room, bathing or showering, eating, getting in or out of bed, using the toilet, handling transportation (driving or navigating public transit), managing medications, shopping and managing finances; %: (95% CI): weighted prevalence and 95% confidence interval; * To test differences between those with and without functional limitation (Pearson Chi-squared test)

The prevalence of selected food groups intake among study participants, and by functional limitation, is displayed in Table 2. Overall, higher prevalence rates were found for weekly consumption of full fat milk (73.8%), regular intake of beans (71.3%), daily consumption of meat (67.1%) and regular fish intake (58.4%). On the other hand, lower prevalence rates were observed for the recommended intake of fruit and vegetables (37.3%), weekly intake red meat or chicken with visible excess of fat (28.2%), regular sweets (17.2%), regular fizzy drinks/artificial juices (12.0%) and high salt intake (7.9%). Significant associations (p<0.05) with functional limitation were found with daily meat consumption (64.1 vs 68.4%, those with and without limitations, respectively), regular fish intake (53.3% and 60.4%, respectively), recommended amount of fruit and vegetable intake (32.1% vs 39.4%, respectively) and excessive salt intake (6.3% vs 8.6%, respectively).

Table 2
Dietary habits of older Brazilians, and by functional limitation status (The Brazilian National Health Survey, 2013

Table 3 presents results of multivariate Poisson regression models for each outcome. After adjusting for sociodemographic characteristics, the dietary patterns that remained significantly associated with functional limitation were: daily meat intake (PR = 0.89, 95% CI: 0.80-0.98), recommended fruit and vegetables intake (PR = 0.86, 95% CI: 0.76-0.96) and regular bean consumption (PR = 0.90, 95% CI: 0.82-0.99).

Table 3
Multivariate analysis of dietary habits and functional limitation among older Brazilians (Brazilian National Health Survey, 2013)

1. At least one difficulty in the following ten activities: dressing, walking across a room, bathing or showering, eating, getting in or out of bed, using the toilet, handling transportation (driving or navigating public transit), managing medications, shopping and managing finances; PR (95% CI): weighted prevalence ratios and their 95% confidence intervals estimated by Poisson regression models and adjusted for age, sex, marital status, household number of residents and educational attainment; *p < 0.05

Results from the multivariate analysis of the association of sociodemographic characteristics with selected dietary habits among those participants with and without functional limitation are shown in table 4. Generally, the association was similar in both functional groups, as follows: women had a positive association with the recommended fruit and vegetable intake and a negative association with regular bean consumption; the number of residents within the household (i.e. three or more) was positively associated with regular bean consumption; schooling level was positively correlated with recommended vegetable intake, and negatively correlated with regular bens intake. Conjugal status showed no significant association with the consumption of all the above mentioned foods in any group. Oldest aged showed a negative association with regular bean intake among those with functioning limitations.

Table 4
Multivariate analysis of sociodemographic factors, selected dietary habits and functional limitation among older Brazilians (Brazilian National Health Survey, 2013)

1. At least one difficulty in the following ten activities: dressing, walking across a room, bathing or showering, eating, getting in or out of bed, using the toilet, handling transportation (driving or navigating public transit), managing medications, shopping and managing finances; *p < 0.05; ** p <= 0.001; PR (95% CI): weighted prevalence ratios and their 95% confidence intervals estimated by Poisson regression models and adjusted for age, sex, marital status, household number of residents and educational attainment

Discussion

The key findings from this study, based on a nationally representative sample of non-institutionalised older Brazilian adults, are: (1) those with functional limitations were less likely to a daily intake of meat, recommended intake of fruit and vegetables and regular ingestion of beans, independent of age, sex and other sociodemographic characteristics; (2) educational attainment was the strongest sociodemographic factor associated to recommended fruit and vegetables intake (higher intake among those with higher educational attainment).
Our findings corroborated previous research based on data from the Brazilian National Household Survey (PNAD) conducted in 1998, 2003 and 2008 that showed higher prevalence of functional limitation among the oldest old, women and those with a low level of education (12,13). Regarding dietary patterns, our study found similar results to earlier descriptive analyses from the Brazilian National Health Survey (2013), based on data from the population aged 18 and older, showing high consumption of healthy foods (such as beans and fish), in contrast with low consumption of fruit vegetables and high intake of food rich in saturated fat (non-lean red meat, chicken or full fat milk) (14, 15).
After adjusting for sociodemographic factors, the dietary patterns of older Brazilians with and without functional limitations were similar, regarding the regular consumption of fish, food rich in fat, fizzy drinks or artificial juices, sweets and salt. On the other hand, the daily meat intake (red meat, chicken and/or fish) was smaller among those with functional limitation. To note that low protein intake may lead to an increased risk to sarcopenia, frailty, falls and fractures resulting into an even greater risk to develop functional limitations (9, 16). Brazilian guidelines (7) and others (17, 18) recommend a diet rich in fruit, vegetables and pulses, like beans, for its important preventive role against the development of non-communicable diseases (17, 18). The current analysis shows that older adults with functional limitations are 10% and 14% less likely to eat regularly beans and the recommended intake of vegetables, respectively.
It is worth mentioning that there are physical, mental and financial barriers which could prevent older adults with functional limitation to have a healthier diet (4). Unfortunately, data from national health surveys usually do not generate information that allows us to identify these barriers. Therefore, the present analysis was focused on sociodemographic factors associated to some healthy diet habits. Overall, the sociodemographic factors associated to daily intake of meat, recommended intake of fruit and vegetables and regular ingestion of beans were similar among those participants with and without functional limitations. Compared to men, women with and without functional limitation reported less meat and beans intake and higher fruit and vegetable consumption. Similar findings regarding women eating more fruit and vegetables were found in Canada (19) but not in South Africa and Iran (20, 21). Furthermore, a qualitative study showed that Canadian women were more aware of the benefits of such food group compared to men (22). Regular ingestion of beans also had a positive and independent association with household number of residents.
As previously mentioned, educational attainment was the strongest sociodemographic factor associated to fruit and vegetable and intake among both those with and without functional limitation. The prevalence of recommended fruit and vegetable intake increased by each level of educational attainment in both functioning groups (with and without functional limitation), with those with 12 or more years of schooling having the highest intake levels. Older Brazilian adults with and without functional limitations with 12 or more years of schooling degree were 207% and 258% more likely to regularly eat fruits and vegetables compared to those with low educational attainment. The positive association between the recommended fruit and vegetables intake and education or income has also been observed in other countries (19, 21, 23). An interesting study conducted in Brazil using data from the Brazilian National Family Budget Survey showed that the total household expenditure on fruit and vegetables is inversely proportional to the price of such food and directly proportional to the household income (24).
In contrast, regular consumption of beans, an important ingredient of the Brazilian staple diet, decreased gradually according to level education in both those with and without functional limitation. Older adults with and without functional limitation with 12 or more years of schooling were17% and 29%, respectively, less likely to eat beans regularly than those with lower education level. A negative association between educational level and beans intake among adults residing in large cities in Brazil has been previously reported (25,26). Beans are an important source of protein, fibre, minerals, vitamins and flavonoids with potential benefits to health (27). This type of food has been considered by some authors as the “meat of the poor” due to its important nutritional value in low income countries (28) and perhaps it has been replaced by other types of food culturally considered “posh” by higher socioeconomic groups’ individuals.
This study has some strengths and limitations. The strength of the present study lies in its large nationally representative sample of older Brazilian with data on functional limitation and dietary habits. Therefore, to the best of our knowledge, this is the first study to compare dietary habits of older Brazilian with and without functional limitations. However, because the data are cross-sectional, we are unable to determine causal relationships and directionality of the observed associations. We are not able to establish if dietary habits were adopted before the development of functional limitation or vice-versa. In addition, the dietary habits module of the interview is rather concise and like any questionnaire on diet is prone to recall bias, leading to under or overestimation of amount of consumption (29). However, it is unlikely that differential associations have affected those with and without functional limitations. Finally, in our analyses we could not establish an individual and/or household income which could directly affect the food choice purchase (24). This limitation was partially addressed by using data on educational attainment which is an important socioeconomic position indicator.
In 2006, the Brazilian Ministry of Health implemented the National Health Policy for the Elderly raising the issue of how important it is to include functional limitation as one of its policies (5). 27 million Brazilian people are currently aged 60 and older (30). Taking into account the findings from the present study, about 5.4 million older adults in Brazil eat less than the recommended amount of fruit and vegetables as indicated by the WHO (31). In conclusion, our findings highlight the importance of assessing dietary habits when investigating functional limitation in older adults. Our findings also highlight the need for public health policies to increase consumption healthy food consumption among those older adults with functional limitations, especially fruit and vegetable intake among those who have low education levels.

Acknowledgements: This study was funded by the Brazilian Ministry of Health, Secretariat of Health Surveillance. MFLC and SVP are fellowship researchers of the Brazilian National Council for Scientific and Technological Development (CNPq).

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A NEW PROPOSAL FOR THE CLINICAL-FUNCTIONAL CATEGORIZATION OF THE ELDERLY: VISUAL SCALE OF FRAILTY (VS-FRAILTY)

E. Nunes de Moraes^1,2, F.M. Lanna², R.R. Santos^1,2, M.A.C. Bicalho^1,2, C.J. Machado^1,3, D.E. Romero⁴

1. Department of Clinical Medicine at the Federal University of Minas Gerais, Brazil; 2. Center for Geriatrics and Gerontology UFMG, Brazil; 3. Department of Preventive and Social Medicine at the Federal University of Minas; 4. Oswaldo Cruz Foundation, Rio de Janeiro, Brasil.

Corresponding Author: Edgar Nunes de Moraes, Professor of the Department of Clinical Medicine at the Federal University of Minas Gerais, Brazil. Director of the Center for Geriatrics and Gerontology UFMG, 117, Alameda Álvaro Celso. Zip Code: 30.150-260, Belo Horizonte. Minas Gerais, Phone: (55) 31 3226-2386, Fax: (55) 31 3226-2386, Email: edgarnmoraes@gmail.com

Abstract

Ageing is closely associated with increasing frailty, and it continues to be defined in various different ways, complicating its practical application in the clinical context. Frailty is commonly used to predict the risk of functional decline, institutionalization or even death. Current models of frailty display significant limitations, because they are unable to encompass all the chronic conditions indicating adverse outcomes. In this article, we propose the Visual Scale of Frailty (VS-Frailty), based on the overall functionality and clinical complexity of elderly individuals. This scale emphasizes the importance of independence in basic, instrumental and advanced Activities of Daily Living (ADL), as well as taking into account the main causes of the functional decline of the elderly, such as sarcopenia syndrome, mild cognitive impairment and multiple comorbidities. The scale places the elderly into 10 categories ranging from completely independent to fully dependent. The scale provides the following advantages over other scales currently used: scope, ease of application, visual clarity, longitudinal monitoring, planning of health services, and the definition of therapeutic goals and prioritization of care. The use of VS-Frailty permits the individualization of the overall diagnosis, thus facilitating continuity of care in a systematized manner, ensuring comprehensive attention to the health of elderly individuals.

Key words: Frailty, disability, classification of the elderly.

Introduction and Motivation

Aging has profound consequences for organization of healthcare systems due to higher incidences of chronic diseases and functional disabilities in elderly populations. However, while diseases may be more common amongst old people, they are not always linked to functional dependency. Ageing, therefore, is not synonymous of disability and dependence, but is related to greater vulnerability.

Aging alone can lead to chronic diseases, but not to functional dependency. Individuals with similar clinical diagnoses may display entirely different functional capacities, and this striking heterogeneity increases with ageing (1). As a result, various authors have asserted the need for a more sophisticated classification of the health status of the elderly (2, 3). We believe that functional capacity should be at the core of any health status classification. Boundaries between the concepts of health, disease, dependency and disability should be also clarified. In this way, health may be defined as a measure of individual’s ability to achieve their aspirations and satisfy their needs, rather than simply as the absence of disease (4).

Well-being and functionality are complementary. Together, they represent the presence of autonomy (individual decision-making power and control over one’s actions, establishing and following one’s own convictions) and independence (the ability to achieve something without external assistance), allowing individuals to look after themselves and their lives. It is important to bear in mind while autonomy and independence are closely related, they are distinct concepts. Physically dependent individuals may still be capable of making their own decisions about daily activities, just as others may be physically able to perform these activities, whilst being incapable of making decisions about the nature of their involvement. According to the International Classification of Functioning, functional decline is defined as a loss of autonomy and/or independence, as it restricts many aspects of life, including social functioning5. Independence and autonomy are thus closely related to complete and harmonious functioning of the following capacities:

• Cognition: the mental capacity to understand and adequately resolve everyday problems;

• Mood/Behaviour: the motivation required to carry out activities and/or participate socially. This includes individual behaviour, which is affected by other mental functions such as sensory perception, thought and conscience.

• Mobility: the individual capacity to move and manipulate one’s environment. This depends on four functional subsystems: aerobic and muscular capacity (mass and function), reach / prehension / grip (upper limbs) and gait / posture / transferring (lower limbs). Control of urinary and fecal sphincters is also considered a pre-requisite for mobility, as incontinence may reduce mobility and restrict the social participation of the individual.

• Communication: the ability to establish a productive relationship with one’s environment, exchange information and express desires, ideas and feelings. This depends on three functional subsystems: vision, hearing and orofacial motor function. The latter refers to the voice, speech and the ability to chew and swallow.

As Moraes (4) writes, the impairment of these systems – manifested in cognitive disability, postural instability, incontinence, immobility and the inability to effectively communicate. These syndromes are known as “geriatric syndromes”. Besides that, presence of chronic medical conditions increases the complexity of clinical management, thus implying increased risk of iatrogenesis. Functional decline and frailty are closely related. The term ‘frailty’ is commonly used to express the degree of vulnerability of the elderly individual to adverse outcomes like functional dependency. It is also used to refer to other levels of vulnerability, such as the risk of institutionalization, or even death. The fact that the term has been defined in several different ways complicates its application in the clinical context (6, 7).

Literature review and multidimensional frailty

Fried and colleagues (8, 9) and Rockwood and colleagues (10, 11) are among the authors who have examined this concept in detail. In 2001, Fried proposed the term ‘frailty’ to represent a geriatric syndrome, of multifactorial nature, characterized by a reduction in energy levels and resistance to stressors, resulting in the cumulative decline of physiological systems. This concept was operationalized in the ‘phenotype of frailty’, validated by the Cardiovascular Health Study. It is characterized by three or more of the following criteria: involuntary weight loss (5 kg in the last year), self-declared exhaustion (according to the Center for Epidemiologic Studies Depression Scale/CES-D), weakness (reduction in muscular strength assessed by grip strength), low level of physical activity (verified by the Minnesota Leisure Time Activities Questionnaire and reduced walking speed (over a timed walk of 4.5 m). The presence of three or more of these features defines the individual as ‘frail’, while the presence of two defines them as ‘pre-frail’. Individuals who do not display any of these criteria are considered robust. This classification excludes individuals suffering from comorbidity and functional dependency and there is a high overlap between the three groups.

In 2005, Rockwood proposed a broader model of frailty, based on the presence of cumulative clinical deficits. This was expressed by the Frailty Index (FI), the result of the application of the Comprehensive Geriatric Assessment. The FI is a weighted measurement, derived from individual accumulation of 30 to 70 clinical problems, including specific diseases (congestive cardiac failure, arterial hypertension, strokes, myocardial infarction, Parkinson’s disease and cancer, among others), symptoms (shaking, bradykinesia, cephalalgia, syncope, among others), functional loss (such as dependence in daily activities, memory loss, problems with mood, changes in gait and balance, falls, immobility and urinary and fecal incontinence) and abnormal laboratory tests. Yet, one criticism that can be made is that the FI is comprehensive, but very broad.

Both Fried’s and Rockwood’s models of frailty have important limitations. Fried’s model is incapable of encompassing all the chronic medical conditions associated with greater risk of functional decline, hospitalization and death. It considers only mobility, in particular, aerobic and muscular capacity, underestimating the importance of other functional capacities such as cognition (12). Moreover, its application requires the use of handgrip equipment, which is not widely available in primary care. Rockwood’s Frailty Index uses a mathematical model based on the accumulation of problems, which are not clearly defined or standardized, and requires the application of a comprehensive geriatric assessment. This assessment brings its own problems, as there is no consensus regarding its structure, and it varies widely in its application. The current challenge, therefore, is to operationalize the concept of frailty, facilitating its recognition and the implementation of actions capable of maximizing individual independence and autonomy and preventing adverse outcomes (13), thereby making the term useful for those considering the prevention of functional disability in the elderly.

Aligned with the idea of understanding frailty in its broader meaning, we propose the concept of multidimensional frailty. It is defined as the reduction of the homeostatic reserve and/or the ability to adapt to biopsychosocial problems, and consequently, greater susceptibility to functional decline. In this multidimensional model, the conditions associated with adverse outcomes can be placed in two categories: clinical-functional and socio-familial. The concept of health, for the elderly individual, should therefore consider information about both these aspects, according to WHO definition of health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

Social conditions, including socioeconomic status, the presence of social support, social engagement and the feeling of self-sufficiency, exert a decisive influence on health, and indeed on an individual’s survival, particularly amongst the elderly (14, 15). For this reason, the socio-familial category considers the importance of factors such as gender, race, level of education, marital status, familial arrangements , recent widowhood, if they are themselves a carer, extent of social participation and support, access to health services and employment situation. Some of these considerations are qualitative and difficult to measure, which limits their use in structured scales.

The variables or factors considered in the clinical-functional category are better structured, though a lack of consensus persists. It takes into account biological, physical, cognitive and psychological factors responsible for functional decline in the elderly. Ageing increases the risk of health problems (senility) related to diseases and external causes (such as traumas and accidents), which are usually manifest in the form of multiple comorbidities (polypathology, polypharmacy and recent hospitalization) and represent the principal cause of disability in the elderly. On the other hand, normal ageing (senescence) may also be associated with the decline of homeostatic reserves and increased susceptibility to problems, principally through immunological activation, which generates a chronic pro-inflammatory state. This in turn permits the development of sarcopenia syndrome, manifested in the reduction of aerobic and muscular capacities, which are considered the principal elements in the phenotype of Frailty 8. Senility and senescence may both therefore lead to functional dependence. Disabilities further compromise homeostatic reserves, producing a vicious cycle, leading to progression of the disabilities, hospitalization and even death. In this multidimensional model, we take into account Fried’s and colleagues’ and Rockwood’s and colleagues’ models, as they are not considered mutually exclusive. On the contrary, they are complementary or synergic, and may both be present in the same individual (Figure 1). The model thus preserves the differences between comorbidities, disabilities and the ‘phenotype of Frailty’. It considers all the components of frailty in the elderly, understood as the presence of disabilities and/or chronic conditions associated with functional decline, institutionalization and/or death.

Figure 1 Ageing and Frailty

Functional decline is therefore the main target of geriatric-gerontological assessment and therapeutic interventions. In this model, functional decline is posited as established and imminent. Imminent functional decline is understood as the presence of chronic conditions indicative of functional dependency, such as sarcopenia and the presence of multiple comorbidities (polypathology, polypharmacy and recent hospitalization).

It is worth re-emphasizing the distinction between sarcopenia as a process and sarcopenia as a syndrome. The process of sarcopenia, understood as the reduction of muscular mass, is the result of neuroendocrine alterations which are responsible for changes to the composition of the ageing body. Such changes include reductions in muscular mass, bone mass and body water content, as well as an increase in fat. The syndrome of sarcopenia, on the other hand, is characterized by the presence of changes in muscular mass and function (strength and muscular performance), that is strictly related to the ‘phenotype of frailty’. In the proposed model, the criteria for the diagnosis of sarcopenia include the presence of three of more features from the phenotype of frailty (weight loss, exhaustion, grip strength, low level of physical activity and a reduction in walking pace), as well as quantitative measurements of muscular mass, associated with measurements of muscular function, such as grip force and walking speed.

A reduction in gait speed is one of the principal determinants of sarcopenia / dynapenia, defined as a gait speed equal to or less than 0.8 m/s. Another strong indication of sarcopenia is a calf circumference equal to or less than 31 cm. Other indications of sarcopenia are significant non-intentional weight loss, or low body mass index (BMI) (less than 22 kg/m2) (16-18). Recently, some authors have suggested that the reduction in neuropsychological reserve is another indication of adverse outcomes in the cognitive area. ‘Cognitive Frailty’ is defined as a heterogeneous clinical syndrome characterized by the presence of physical Frailty (‘phenotype of Frailty’) associated with cognitive decline involving mild cognitive impairment (CDR 0.5) (19).

The presence of multiple medical conditions is related to increasing use of healthcare systems and higher risk of iatrogenesis, disabilities, institutionalization and even death (20). Thus, multiple medical conditions contribute to imminent functional decline. However, the definition of multimorbidity, and its operationalization, have yet to be clearly established. Multimorbidity can be defined as a combination of acute and/or chronic medical conditions, associated with a range of biopsychosocial risk factors, such as polypharmacy, lifestyle habits, and excessive use of healthcare systems, among others (21). In the model proposed here, we define multimorbidity as the presence of one or more of three clinical conditions: polypathology (simultaneous presence of five or more chronic medical conditions, attacking different physiological systems); polypharmacy (regular and systemic use of five or more medications per day for different chronic conditions); or recent hospitalization (in the last six months).

In addition to the presence of multiple comorbidities, evidence of sarcopenia syndrome and mild cognitive impairment, we include the presence of established functional decline as a determinant of Frailty. As such, functional dependency may be considered both a cause, and at the same time, an effect of Frailty (22, 23).

The overall functionality of the individual has always been fundamental for any classification of the elderly. In 1943, Marjory Warren, considered the ‘mother of geriatrics’ (24), proposed a classification based on the presence of various types of disability, such as postural instability, immobility, urinary incontinence and cognitive disability. This pioneering classification of elderly patients at an infirmary enabled the planning of the human and material resources necessary to implement specific actions for each group of elderly individuals. In 1963, Katz developed an index capable of categorizing individuals according to the level of dependence in Activities of Daily Living (ADL) related to self-care (25). The Katz index made a clear distinction between independent and dependent individuals in ADL, and included a hierarchy for the dependent individuals. Elderly individuals may therefore be categorized as:

• Independent: capable of carrying out basic daily activities in an independent manner;

• Semi-dependent: displays difficulty in carrying out one of the functions influenced by culture and learning (bathing and/or getting dressed and/or using the toilet);

• Incomplete dependent: displays impairment in one of the simple vegetative functions (transferring and/or continence), as well as requiring assistance in bathing, getting dressed and using the toilet. The isolated presence of urinary incontinence should not be taken into account, as it is a function rather than an activity;

• Complete dependent: displays impairment in all functions influenced by culture and learning, as well as in simple vegetative functions, including the ability to eat without assistance. This is the maximum degree of functional dependence.

In 1969, Lawton and Brody (26) confirmed the importance of assessing the functionality of the individual in their basic daily tasks, but they also proposed the assessment of more complex abilities, denominated instrumental ADL, related to self-maintenance. Elderly individuals may therefore be independent, partly dependent or completely dependent in instrumental ADL. Usually, functional decline follows a hierarchy, beginning with the more complex (advanced and instrumental) ADL, until the impairment of activities related to self-care (basic ADL). Moreover, it may be a consequence of impairment in isolated functions or connected functional areas. Clinico-functional classification of the elderly individual depends directly upon this functional classification. These scales (Katz’s and Lawton-Brody’s scales) are vital for the objective assessment of the elderly individual, and for the creation, implementation and evaluation of a care plan.

The VS-Frailty proposal

While ageing is closely linked to the frailty there is no direct cause and effect relation between the two. The two phenomena do not follow the same pattern of evolution, and elderly individuals of the same age may display highly heterogeneous conditions (27). Thus, age alone is not a good indication of Frailty.

To express more clearly the various sub-groups of elderly individuals, we propose the use of the Visual Scale of Frailty (VS-Frailty), based on their functionality and clinical complexity. Visual analogic scales have been used to assess a range of issues related to human health, particularly those of a multidimensional nature and those which display a dynamic character over time, such as pain, mood and dyspnoea, among others28. This permits continuous measurement within an established set of values, in a linear and proportional manner, taking into account both objective and subjective factors. The VS-Frailty thus encompasses extremes, from the maximum and minimum degree of vitality (homeostatic reserve) and frailty (vulnerability). These extremes are linked by a straight line, continuous and declining, upon which the health of the elderly individual may be marked. Ten clinical-functional categories were defined, which vary continuously within the pre-established range of values. Elderly individuals may therefore be categorized as illustrated in Figure 2.

Figure 2 Visual Analogue Scale of Frailty (VAS-Frailty)

ROBUST: Elderly individuals who display good homeostatic reserve, being therefore capable of managing their lives in an independent and autonomous manner. They do not display any functional disability or any chronic medical condition associated with greater vulnerability. Care must be directed towards the maintenance of the individual’s autonomy and independence, through measures which promote health, as well as primary and secondary preventive measures and appropriate clinical management of diseases according to their respective established guidelines. This group is divided into three sub-categories:

• Category 1: Elderly individuals who display the maximum degree of vitality. They retain independence in all advanced, instrumental and basic ADL, as well as being free of illness and other risk factors apart from their age. They do not display any medical conditions indicative of adverse outcomes.

• Category 2: Elderly individuals independent in all ADL, but who display medical conditions of low clinical complexity, such as arterial hypertension (without complications) and/or the presence of risk factors such as tobacco smoking, dyslipidaemia and osteopenia, among others.

• Category 3: Elderly individuals independent in all ADL, but who display well-established chronic degenerative diseases of higher clinical complexity, such as complicated arterial hypertension, diabetes mellitus, a history of transient ischemic attacks, strokes (without further consequences), chronic renal disorder, heart failure, chronic obstructive pulmonary disease, osteoarthritis; coronary artery disease, with or without acute myocardial infarction; peripheral artery disease, cancer, osteoporosis and atrial fibrillation, among others. In these individuals, the presence of these conditions is not associated with functional limitation, and in general, they appear in isolation. Individuals displaying one or two criteria of the ‘phenotype of Frailty’ also fall into this category.

AT RISK OF FRAILTY: Elderly individuals capable of managing their life in an independent and autonomous manner, who remain in a dynamic state between senescence and senility, resulting in the presence of certain functional limitations (imminent functional decline), but without functional dependency. They display one or more of the chronic medical conditions indicative of adverse outcomes, such as evidence of sarcopenia syndrome, mild cognitive impairment and/or the presence of multiple comorbidities. The aim of treatment must be to prevent functional decline through the correct handling or correct approach to managing polypathology and polypharmacy, with an emphasis on the following, in order of importance: suspension of inappropriate medication, definition of personalized therapeutic goals, prioritization of care, diagnosis and treatment of underdiagnosed and/or undertreated medical conditions, rehabilitation, primary and secondary prevention. This group corresponds to categories four and five of the VS-Frailty:

• Category 4: These are elderly individuals who display symptoms of sarcopenia syndrome, mild cognitive impairment (MCI) and/or multiple comorbidities (polypathology, polypharmacy or recent hospitalization), but who remain independent in all ADL, including advanced ADL, defined as activities related to social integration, productive, recreational and/or social activities.

• Category 5: These are elderly individuals who display symptoms of sarcopenia syndrome, mild cognitive impairment and/or multiple comorbidities, and who also have begun to display functional decline in advanced ADL. However, they remain independent in instrumental and basic ADL.

From Category 6 on, classification is essentially based on the presence of established functional decline, which is the consequence of major geriatric syndromes such as cognitive disability, postural instability, incontinence and communicative disability. These patients are also associated with iatrogenesis and family insufficiency, and are likely to suffer from other chronic medical conditions.

FRAIL: Elderly individuals suffering from established functional decline, who are incapable of managing their own lives, as a result of single or multiple disabilities. The aim of treatment should be the recovery of the individual’s autonomy and independence. This group corresponds to the categories six, seven, eight, nine and ten of the VS-Frailty:

• Category 6: Individuals who display partial functional decline in the instrumental activities of daily living, but who remain independent in basic ADL.

• Category 7: Individuals who display functional decline in all the instrumental activities of daily living, but who remain independent in basic ADL.

• Category 8: Individuals who display total functional decline in instrumental ADL, as well as semi-dependence in basic ADL: impairment of one of the functions influenced by culture and learning (bathing, getting dressed and/or using the toilet).

• Category 9: Individuals who display total dependence in instrumental ADL, alongside partial dependency in basic ADL: impairment of one of the simple vegetative functions (movement and/or continence), as well as requiring assistance to bathe, get dressed and use the toilet. The isolated presence of urinary incontinence should not be taken into account, as it is a function and not an activity.

• Category 10: Individuals who display the maximum degree of Frailty, and therefore the highest level of functional dependence. They require assistance even to eat. On Katz’s index, they are classified at Stage G (25).

Definition of the clinical-functional category should consider the best current performance of ADL. So, if the individual is capable of various instrumental ADL, they should be placed in category 7, even if they are unable to carry out a basic ADL. As well as functional heterogeneity, frail individuals also display differences regarding clinical complexity and the need for specialized geriatric-gerontological assistance. In this sense, frail individuals may also be categorized according to the following definitions:

o Low Complex Frail Individual: Displays established functional decline, with low potential for clinical-functional reversibility. With these individuals, intense geriatric-gerontological assistance is not required and the aim of treatment should be the prevention of functional deterioration.

o Highly Complex Frail Individual: Displays functional dependency in ADL, together with medical conditions that are difficult to manage as a result of doubts regarding diagnosis or therapy. The term ‘Highly Complex’ suggests high potential for clinico-functional reversibility or quality of life. These individuals benefit most from intensive monitoring by teams of geriatric-gerontological specialists.

o Frail Individual in Final Stage of Life: Displays a high degree of functional dependency and life expectancy is estimated at less than six months. Despite the existence of a clear link between higher levels of functional decline and higher mortality rates, some individuals may be able to function relatively well despite suffering from diseases that present a high risk of mortality, such as certain types of neoplasia (terminally ill). The aim of treatment should be palliative care, based on the comfort of the patient and their family members.

The scale provides the following advantages over the scales already discussed and currently used:

• Scope: the scale is based on the multidimensionality of factors that determine geriatric health (29, 30), without minimizing the importance of diseases or physical changes, including the frailty indicators as described by Fried and colleagues (9), as well as diseases, polypathology and polypharmacy;

• Ease of application: it does not require any sophisticated or hard-to-obtain tools, and may be applied in any environment of geriatric care, such as outpatients’ clinics, patients’ homes, care homes, day centres and hospitals. It unites objective and subjective aspects in its assessment of elderly individuals.

• Visual clarity: the scale is visual and it incorporates fundamental concepts for the understanding of the ageing process, such as senescence, senility, vitality, frailty, functional decline and ADL. The categories 1 to 10 take into account the heterogeneity of elderly individuals of the same age group;

• Longitudinal monitoring: permits longitudinal monitoring of the health of the elderly individual, facilitating the visualization of the results of geriatric-gerontological treatment;

• Planning of health services: the scale establishes objective criteria for geriatric-gerontological care;

• Definition of therapeutic goals and prioritization of care: the clinico-functional categorization permits the definition of personal and specific objectives for each patient. With robust individuals, therapeutic goals will be similar to clinical guidelines regarding diseases. By contrast, with highly dependent individuals, or with individuals reaching the end of their life, therapeutic goals must prioritize comfort, as functional loss is critical, and classical preventive strategies should be revised.

The use of VS-Frailty makes possible the individualization of the overall diagnosis of the individual, thus facilitating continuity of care in a systematized manner, ensuring comprehensive attention to the health of the elderly individual.

Conflict of interest: No potential conflicts of interest were disclosed.

Author Contributions: Edgar N. Moraes: study concept and design, preparation of paper. Flávia M. Lanna: study concept and design, preparation of paper. Rodrigo R. Santos: study concept and design, preparation of paper. Maria A.C Bicalho: study concept and design, preparation of paper. Carla J. Machado: study concept and design, preparation of paper. Dália E. Romero: study concept and design

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CLINICAL CHARACTERISTICS ASSOCIATED WITH DYSPHAGIA IN THE HOSPITALIZED ELDERLY

Department of Rehabilitation, St. Francis Hospital, Nagasaki City, Japan

Corresponding Author: Yoshitoshi Kuroda, Department of Rehabilitation, St. Francis Hospital, 9-20 Komine-machi, Nagasaki City, 852-8125 Japan, Telephone: +81-95-846-1888, Fax: +81-95-845-7600, Email: kuroda@athena.ocn.ne.jp

Abstract

The aim of this study was to determine the factors associated with dysphagia in the hospitalized older adults. The dysphagia group consisted of 46 patients (23 men and 23 women) while the non-dysphagia group consisted of 40 patients (10 men and 30 women). The measurements included Mini Nutritional Assessment Short-Form (MNA-SF) scores, serum albumin levels, anthropometrics, and a mobility index. The dysphagia group was older and had significantly higher rates of male sex, respiratory disease on admission, dementia, other neurological disease, and impaired mobility than the non-dysphagia group. The dysphagia group also showed significantly lower values in nutritional measurements including MNA-SF scores, serum albumin levels. Logistic regression analysis showed that the factors significantly and independently associated with dysphagia were impaired mobility, dementia, and male gender. The results of present study showed that hospitalized elderly with dysphagia are likely to present with problems including physical and mental disabilities and malnutrition.

Key words: Dysphagia, elderly, hospitalization, disability, malnutrition.

Introduction

Dysphagia is a common condition among the elderly. Recent studies have reported the prevalence of oropharyngeal dysphagia as 27.2% in independently living elderly (1) and 47.4 % in hospitalized elderly (2). Studies have also reported that dysphagia in the older population is associated with malnutrition (2-4), impaired activities of daily living (1, 4), increased rates of lower respiratory tract infection (3, 5), and higher mortality rates (5). These findings clearly indicate that dysphagia is a major health problem in this population.

One reason for the high prevalence of dysphagia in the elderly may be that diseases that can cause dysphagia increase with age (6). However, it is not uncommon to observe elderly patients developing dysphagia in the absence of any disease that is known to directly cause dysphagia. Another reason may be that a wide variety of stressors, such as acute illness, can induce dysphagia because the elderly have a diminished functional reserve available for swallowing (6). Although the latter hypothesis seems plausible, it does not fully explain the underlying mechanism considering that some patients have persistent or progressive dysphagia in the absence of acute illness. Thus, currently there are no well-grounded hypotheses that can account for the underlying mechanism that result in the increased incidence of dysphagia in the elderly.

In order to provide effective intervention, further understanding of the underlying mechanism is mandatory. In the present study, we conducted a retrospective investigation comparing clinical characteristics between those with and without dysphagia among the hospitalized elderly. The aim of this study was to determine the factors associated with dysphagia in hospitalized older adults.

Subjects and methods

Subjects were retrospectively selected from patients admitted to a hospital for acute care between April 2013 and September 2014. Included were patients aged 65 years or older who were rated as having “malnutrition” or being “at risk of malnutrition” by the Mini Nutritional Assessment Short-Form (MNA-SF) (7) and who underwent a series of nutritional and physical assessments as described below. Excluded were those with active malignancy and those with feeding tubes. A total of 86 patients (33 men and 53 women) with a mean age (standard deviation [SD]) of 85.7 (7.7) years were enrolled as subjects. Primary diseases on admission were respiratory disease (n = 46), orthopedic disease (n = 8), digestive disease (n = 7), cardiac disease (n = 6), renal disease (n = 4), inactive cancer (n = 4), and others (n = 11). Patients who were referred to speech therapists for swallowing management during hospitalization were defined as the dysphagia group and those who had no problems with swallowing, as the non-dysphagia group. The dysphagia group consisted of 46 patients (23 men and 23 women) while the non-dysphagia group consisted of 40 patients (10 men and 30 women). The severity of dysphagia was evaluated using the food intake level scale, with a range from 1 (no oral intake and no swallowing training) to 10 (normal oral food intake) (8). The scores of the dysphagia group ranged from 3 to 9 (median = 5) while all subjects in the non-dysphagia group scored 10.

Nutritional assessment included MNA-SF scores, calf circumference (CC), mid-upper arm circumference (MUAC), mid-arm muscle circumference (MAMC), and serum albumin levels. Physical ability was evaluated with a mobility index, measured as follows: 0, completely bedridden; 1, able to sit with a little assistance; 2, able to sit without assistance; 3, able to move from bed to wheel chair with a little assistance; 4, able to move from bed to wheelchair without assistance; 5, able to walk with a little assistance; and 6, able to walk without assistance. cymbalta The two groups were compared for the age, sex, presence of respiratory disease (as a primary disease on admission), dementia, and other neurological diseases, and the above variables. In order to make the analyses more readily comparable, the continuous variables were converted into dichotomous variables based on cut off points. The cut-off points were applied for age (85 or older), MNA-SF score (< 8, suggesting malnutrition), CC (< 31.3 cm for men and < 29.9 cm for women), MUAC (< 22.5 cm for men and < 20.8 cm for women), MAMC (< 19.1 cm for men and < 16.6 cm for women), and serum albumin levels (< 2.8 g/dL). The cut-off points of the anthropometrics were values 2 standard deviations below the normal population aged 40-44 years for each sex (9).

Comparative analyses between the two groups were performed using the Student’s t-test, Mann-Whitney test, and chi square test. Logistic regression analysis was performed using dysphagia as the dependent variable and other dichotomous measures as independent variables. In the multivariate analysis, respiratory disease was excluded from the analysis because it is clearly a frequent result of dysphagia (5). Statistical significance was set at p < 0.05.

Results

Comparison between the dysphagia group and the non-dysphagia group is shown in Table 1. The dysphagia group was older (p < 0.001) and had significantly higher rates of male sex (p = 0.014), respiratory disease on admission (p < 0.001), dementia (p < 0.001), other neurological disease (p = 0.047), and impaired mobility (p < 0.001) than the non-dysphagia group. The dysphagia group also showed significantly lower MNA-SF scores (p < 0.001) and serum albumin levels (p = 0.03), but no significant differences in MUAC (p = 0.141) and MAMC (p = generic cymbalta 0.206) measures. The results from the analysis using dichotomous variables were similar to those from the above analysis using continuous variables with the exception that the dysphagia group exhibited a significantly higher rate of decreased MAMC compared with the non-dysphagia group (p = 0.018), and the difference in the rate of decreased CC did not reach a significant level ( p = 0.090).

Table 1 Comparison between the dysphasia group and non-dysphagia group

Logistic regression analysis showed that the factors significantly and independently associated with dysphagia were impaired mobility (OR 13.70 95% CI 3.43-54.80), dementia (OR 11.0 95% CI 3.01-40.10), and male gender (OR 6.81 95% CI 1.69-27.50) (Table 2).

Table 2 Variables associated with dysphagia (multivariate logistic regression analysis)

Discussion

The dysphagia group was older than the non-dysphagia group, which was consistent with previous studies (1-3, 5). It is of note that our results showed that male gender was significantly associated with dysphagia, which was inconsistent with the findings from Spanish studies (1-3, 5). Considering that a Korean study (10) and a Japanese study (11) also reported the association of male gender with dysphagia, such an association may be related to ethnicity.

Dementia and neurological disease were significantly associated with dysphagia which was consistent with previous findings (2, 5). However, such an association was not observed in a study in independently living elderly (3), which was probably related to the very low prevalence (< 10%) of each condition in the study cohort. Therefore, we consider that the association between dysphagia and dementia or neurological condition is typically apparent only in clinical populations.

The dysphagia group exhibited significantly impaired mobility compared to the non-dysphagia group. Furthermore, the multivariate analyses showed that impaired mobility was the most important predictor of dysphagia. Given that many studies have also demonstrated the association between dysphagia and activities of daily living in the elderly (1-5), the relationship between swallowing impairment and physical disability is of importance. Recent studies have proposed that sarcopenia is a common underlying cause of impaired physical ability and dysphagia (12-14). Further investigations regarding the effects of the loss of muscle mass and strength on swallowing function are needed.

The dysphagia group showed significantly lower values in the nutritional measures of MNA-SF score and serum albumin levels, suggesting an association between dysphagia and malnutrition. Anthropometric assessment using dichotomous variables also showed that the dysphagia group had significantly higher rate of decreased MAMC, suggesting a reduction of muscle mass may be a predictor for dysphagia. The difference in CC lost significance after applying the dichotomous variables, which was probably related to the very high prevalence (85% or more) of the decreased condition.

Taken together, the results of the present study showed that older patients with dysphagia are likely to present with impaired mobility, dementia, and malnutrition. The results were mostly consistent with recent findings (2-5). We consider that dysphagia in elderly patients is rarely a condition specific to the swallowing mechanism, and in many cases, it can be understood as part of a systemic decline including physical, mental, and nutritional deterioration. Currently, there is no sound evidence that traditional dysphagia intervention techniques are effective for this clinical population. Given that many countries are facing challenges associated with aging populations, there is a great need to clarify the underlying mechanism of dysphagia in the elderly in order to improve its prevention and treatment.

The limitations of this study were as follows: First, the study sample was small and obtained from one institution, which may limit the generalization of the results. Second, dysphagia was assessed only with an observational scale. Third, the cross-sectional design did not allow for causative analysis.

In conclusion, hospitalized elderly with dysphagia are likely to present with problems including physical and mental disabilities and malnutrition.

Conflicts of interests: The author has no conflict of interest to disclosure, and do not receive any funding for this study.

References

1. Serra-Prat M, Hinojosa G, Palomera E, Arreola V, Clavé P. Prevalence of oropharyngeal dysphagia and impaired safety and efficacy of swallowing in independently living older persons. JAGS 2011; 59: 186-187.

2. Carrión S, Cabré M, Monteis R, Roca M, Palomera E et al. Oropharyngeal dysphagia is a prevalent risk factor for malnutrition in a cohort of older patients admitted with an acute disease to a general hospital. Clin Nutr 2015; 34: 436-442.

3. Serra-Prat M, Palomera M, Gomez C, Sar-Shalom D, Saiz A et al. Orpharyngeal dysphagia is a risk factor for malnutrition and lower respiratory tract infection in independently living older persons: a population-based prospective study. Age Aging 2012; 41: 376-381.

4. Wakabayashi H, Matsushima M. Dysphagia assessed by the 10-item eating assessment tool is associated with nutritional status and activities of daily living in elderly individuals requiring long-term care. J Nutr Health Aging 2015. doi:10.1007/s12603-015-0481-4.

5. Cabré M, Serra-Prat M, Force LI, Almirall J, Palomera E et al. Oropharyngeal dysphagia is a risk factor for readmission for pneumonia in the very old persons: observational prospective study. J Gerontol A Biol Sci Med Sci 2014; 69: 330-337.

6. Ney D, Weiss J, Kind A, Robbins J. Senescent swallowing: impact, strategy and interventions. Nutr Clin Pract 2009; 24: 395-413.

7. Kaiser ML, Bauer JM, Ramsch C, Uter W, Guigoz Y et al. Validation of the Mini Nutritional Assessment short-form (MNA-SF): a practical tool for identification of nutritional status. J Nutr Health Aging 2009; 13: 782-788.

8. Kunieda K, Ohno T, Fujishima I, Hojo K, Morita T. Reliability and validity of a tool to measure the severity of dysphagia: the food intake level scale. J Pain Symptpm Manage 2913; 46: 201-206.

9. Hosoya N, Okada T, Muto Y, Yamamoru H, Tashiro T et al. Japanese anthropometric reference data 2001 (JARD 2001). Jpn J Nutr Assess 2002; 19(Suppl): 1-81 (Japanese).

10. Yang EJ, Kim MH. Lim JY, Paik NJ. Oropharyngeal dysphagia in a community-based elderly cohort: the Korean longitudinal study on Health and Aging. J Korean Med Sci 2013; 28: 1534-1539.

11. Furuta M, Komiya N. Akifusa S, Shimazaki Y, Adachi M et al. Interrelationship of oral health status, swallowing function, nutritional status and cognitive ability with activities of daily living in Japanese elderly people receiving home care services due to physical disabilities. Community Dent Oral Epidemiol 2013; 41: 173-181.

12. Kuroda Y. Relationship between swallowing function, functional and nutritional status in hospitalized elderly individuals. Int J Speech Lang Pathol Audiol 2014; 2: 20-26.

13. Wakabayashi H. Presbyphagia and sarcopenic dysphagia: association between age, sarcopenia, and deglutition disorders. J Frail Aging 2014; 3: 97-103.

14. Maeda K, Akagi J. Sarcopenia is an independent risk factor of dysphagia in hospitalized older people. Geriatric Gerontol Int 2015. doi:10.1111/ggi.12486.

ADVANCING RESEARCH BY CLEARLY LABELING MEASURES OF PHYSICAL FUNCTION: EXTRACTING AMBULATION AND STAIR-CLIMBING FROM “MOBILITY DISABILITY”

C. Siordia¹, A.N. Lewis²

1. PhD, Graduate School of Public Health, University of Pittsburgh; 2. PhD, College of Health and Behavioral Studies, James Madison University

Corresponding Author: C Siordia, 30 North Bellefield Ave, Pittsburgh, PA 15213. Phone: 1-142-383-1708. Email: cas271@pitt.edu

Abstract

The term “mobility disability” is used in different academic disciplines to discuss conceptualizations of physical movement. Inadequate attention has been paid to how this umbrella term refers to various forms of measurements on both hypothetical and enacted function. Refining what is meant by mobility disability may impact clinical practice by providing more specific information to clinicians. Less ambiguous labeling may have the potential to advance research by lowering measurement imprecision. We complement discussion by presenting empirical analysis on 5,995 participants (aged > 65) from National Health and Aging Trends Study (NHATS-2011). Ambiguous labeling of mobility may unintentionally obscure what is known about perceived capacity for ambulation and stair-climbing. Because creating low-cost and readily-available measures of health in the population has the potential to advance public health knowledge, efforts should continue to standardize and clarify measures of mobility. Key words: Ambulation, disability, function, labeling; measurement, mobility.

Key words: Ambulation, disability, function, labeling, measurement, mobility.

Introduction

The term “mobility” is widely used in health, disability, clinical, and rehabilitation research. The term is broad and encompasses a wide variety of phenomena. The term “mobility” was recently defined in the Disability and Society journal as “the capacity to navigate one’s way through different spaces and places” (1). The term mobility also accompanies other forms of movements, such as those with “power mobility devices” (2) and has been used to define migratory behaviors such as “cross-border mobility” (3). Measuring movement, be it independent or with assistance, is important as it quantifies “existential implications of the performance of place through mobility” (4). The “mobility disability” label generally refers to: ability to perform physical function tasks. The term has been defined in one or multiple items from a wide variety of subjective and objective measurements (5-12), like two consecutive self-reports of having difficulty walking ¼ mile or climbing 10 stairs (13). A review of instruments used to assess mobility in older adult populations is available elsewhere (14). Research has used a wide array of measures for mobility disability. While common language facilitates discourse, imprecise terminology has the potential to hide the fact that inter-study comparability on (what appears to be) the same topic is not possible. Standardizing the use of highly specified labels through public consensus may help solve this issue.

As eloquently explained by others (15), it is important to understand how “capacity to function” and “actual performance” differ: the first refers to function in the hypothetical sense while the latter to function in the enacted sense. More specifically, self-reports on ability to perform physical function tasks measure hypothetical movements while observed performance measures enacted movements. Technically, hypothetical movement refers to an individual’s perceived potential to perform a particular task while enacted movements refer to an individual’s ability to perform a task as per validation by an external evaluator. Treating hypothetical and enacted mobility as the same thing—by using one label—has the potential to obscure what is understood about an individual’s physical capacity.

Unlike enacted physical movements that are objectively measured by a trained observer or electronic device like an accelerometer, assessment of hypothetical mobility is undertaken by asking individuals to self-evaluate and report their ability to perform a particular task. The labeling of subjective measures is the primary concern of this commentary. In particular, we are concerned with self-reported ability to walk long distances and climb-steps. Self-reported ability to walk long distances measures an individual’s perceived potential to walk. Thus, the following “root label” is recommended: Perceived Potential for Ambulation Ability (PPAA). The root label PPAA could be more highly specified by including a “sub-label”—like the “distance” mentioned in the question. For example, if a 1 mile or 1 kilometer question is used, the following sub-labels could be added: PPAA1m; PPAA1k.

Note the term “ambulation ability” has been used before (16) and to refer to something different than what is being discussed in this commentary. Because survey questions pertaining to ability to walk over long distances presumably refer to “linear ambulation” (i.e., walking horizontally on a flat surface with 0° of incline), walking up steps is framed in this commentary as being radically different. Hypothetically, stair-climbing in the respondent’s mind refers to “non-linear ambulation” (i.e., walking upwards on flat surfaces over a non-0° incline). Because linear and non-linear ambulation may differ in terms of physical demands, they should be labeled separately. Self-reported ability to walk-up stairs/steps measures an individual’s perceived potential to climb stairs/steps. Thus, the following root label is recommended: Perceived Potential for Stair-Climbing Ability (PPSCA). If a survey question on ability to walk-up “one flight of steps” or “20 steps” is used, the root label PPSCA could be further specified with sub-labels as follows: PPSCA1flight; PPSCA20stairs.

Research on the biomechanics of ambulation has shown that stair-climbing is more demanding than linear ambulation (15). Perceived potential to walk over a long distance or climb steps can be evaluated by at least two methods: (1) memory retrieval of relevant event; (2) or by evaluating capacity from a cognitive model. Perceived Potential from Memory Retrieval (PP-MR) refers to self-evaluations from actual events retrieved from memory. For example, when asked about ability to walk up 20 steps, a person may remember attempting the task and failing (or succeeding) and use that as the method for determining their capacity. Perceived Potential from Cognitive Model (PP-CM) is more difficult to describe and refers to using mental scenarios to self-evaluate ability to perform tasks. Because survey questions, in theory, have the ability to lead a respondent to self-evaluate his or her ability to perform a particular physical function task by, presumably, invoking cognitive representations of the environments, PP-CM is presumed to be possible.

Because linear and non-linear ambulation exert different biomechanical demands and because their subjective assessment may magnify how self-evaluation processes (i.e., PP-MR or PP-CM) affect perceived potential to perform tasks, walking (PPAA) and climbing (PPSCA) should be explored separately (17). By extension, these arguments could be used to explain why combining PPAA and PPSCA into one composite score has the potential to create an ambiguous measure of physical capacity—where (PPAA + PPSCA) = increased potential for measurement bias (18-20). In order to show evidence of how our discussion may be able to disambiguate research by highlighting the presence of “ambiguous mobility disability phenotypes”, we provide a brief empirical analysis.

Methods

Our analysis uses “Round 1” data (year 2011) from the National Health and Aging Trends Study (NHATS) of persons aged > 65 designed to investigate physical function in later life (22). Details of the study have been published before (22). Our brief analysis includes Latinos (LAT), Non-Latino-Blacks (NLB), and Non-Latino-Whites (NLW) who completed a 3-meter walk test without the use of any assistive device or person. A total of 5,995 NHATS participants are used in the analysis.

PPAA is computed from answers to the following NHATS questions: In the last month, were you able to walk 3 blocks by yourself and without your cane or walker?—could be labeled as “PPAA3blocks”; and In the last month, were you able to walk 6 blocks, or about half a mile, by yourself and without your cane or walker?—could be labeled as “PPAA6blocks”. Those responding “yes” receive a “1” on a binary variable for each question. We then combined them as follows: PPAA=0 if unable to walk 3 or 6 blocks; PPAA=1 if only able to walk 3 blocks; and PPAA=2 if able to walk 3 and 6 blocks. PPSCA is computed from answers to the following NHATS questions: In the last month, were you able to walk up 10 stairs by yourself and without your cane or walker?—could be labeled as “PPSCAA10steps”; and In the last month, were you able to walk up 20 stairs, about two flights, by yourself and without your cane or walker?—could be labeled as “PPAA20steps”. Those responding “yes” receive a “1” on a binary variable for each question. We then combined them as follows: PPSCA=0 if unable to walk up 10 stairs; PPSCA=1 if only able to walk up 10 stairs; and PPSCA=2 if able to walk up 20 stairs. PPAA and PPSCA were summed to create the Composite Score (CS) and produce the following groups: “clearly” able disability” (CS=0); “ambiguous mobility disability phenotype” (CS= 1); and “clearly” unable to perform tasks (CS=2).

Because PPAA, PPSCA, and SC represent “subjective” measures, we contrast their distribution by an “objective” measure”: gait speed. The three-meter “usual pace” gait speed was used as part of the short physical performance battery (SPPB) test and was assessed at the participant’s home by a trained interviewer (22). We measure gait speed as “meters per-second” (m/sec). We then combined PPAA scores with “normal” gait speed (i.e., >1.01 m/sec) as advised elsewhere [22] and “abnormal” gait speed (i.e., <1.00 m/sec) to create the “PPAA by normality of gait speed” groups presented in Table 1. We also combined PPSCA scores with normal and abnormal gait speed to create the “PPSCA by normality of gait speed” groups and additionally combined CS scores with normal and abnormal gait speed to create the “CS by normality of gait speed” groups.

We present the distribution of PPAA, PPSCA, and CS scores by race-ethnic groups and by normality of gait speed. We also provide multivariate logistic regression results predicting “ambiguous mobility disability phenotype” (i.e., CS=1) while adjusting for: race; ethnicity; sex; age; and educational attainment—using the following categories: < junior high school (>1st-8th grade); high school (includes 9th-12th grade and high school graduates); some college (includes vocational, technical, business, or trade school certificate or diploma beyond high school level); and > college graduate (includes: some college but no degree; associate’s degree; bachelor’s degree; and master’s, professional, or doctoral degree). We managed data and regressions using SAS 9.3® software. We discussed “percent change in the expected likelihood”: [100×(OR-1)]—i.e., [100×(eβx-1)].

Results

Table 1 shows descriptive statistics for sample of 5,995 observations. Table 2 presents how NLBs, NLWs, and LATs are distributed over the variables used to predict ambiguous mobility disability phenotype. From Table 2, see that about one-fourth of all study subjects

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in the analysis sample are categorized as having an ambiguous mobility disability phenotype; the majority are NLWs; females; born in the US; and have a high school education or below. Table 3 presents the regression results. As may have been expected from a previous publication (22), the following groups are associated with having a greater likelihood of having an ambiguous mobility disability phenotype: females; those over age 75; and those with some college education or below. For example, when compared to those with a college education, individuals with a junior high education or below are 72% more likely to have an ambiguous mobility disability phenotype—i.e., a complex combination between ability to walk blocks and climb stairs. When compared to those males, females are 65% more likely to self-report their perceived potential for mobility over the counter alternative to report an ambiguous mobility disability phenotype. The regression results suggest that ambiguous mobility disability phenotype is not normally distributed when “markers of social stratification” are considered (23).

Table 1 Distribution of PPAA, PPSCA, and Composite Score by Normality of Gait Speed

1. Perceived Potential for Ambulation Ability; 2. Non-Latino-White; 3. Non-Latino-Black; 4. Latino; 5. Perceived Potential for Step-Climbing Ability; 6. Composite score (PPAA+PPSCA); 7. Gait > 1.01 m/sec; 8. Has normal gait and report inability to walk or climb steps; 9. Has normal gait and reports some inability to walk or climb steps; 10. Has normal gait and reports full ability to walk and climb steps; 11. Gait < 1.00 m/sec; 12. Has abnormal gait and report inability to walk or climb steps; 13. Has abnormal gait and reports some inability to walk or climb steps; 14. Has abnormal gait and reports full ability to walk and climb steps

Table 2 Descriptive statistics for variables in regression model

1. Non-Latino-White; 2Non-Latino-Black; 3. Latino; 4. Has a Composite Score (PPAA+PPSCA) that is between 2 and 3—which may represent a multitude of different scenarios between perceived potential to walk blocks and climb-steps

Table 3 Results from multivariate logistic regression model predicting “ambiguous mobility disability phehotype”1

***α<0.001 **α<0.01; 1. Has a Composite Score (PPAA+PPSCA) that is between 2 and 3—which may represent a multitude of different scenarios between perceived potential to walk blocks and climb-steps; 2. Odds ratio; 3. 95% Wald lower confidence limit; 4. 95% Wald upper confidence limit; 5. Percent change:[(odds ratio-1)*100]

Conclusions

From our introductory discussion, we concluded that advancing research may be plausible through clear labeling of mobility-related measures. Although cumbersome, the use of technical labels has the potential to improve the level of precision in the public discourse over “mobility disability.” Improving clarity in the labeling of measures may help clinicians better understand risk factors for abnormal lower extremity mobility. Use of the label mobility disability to refer to some measure of physical capacity is not only customary; it also empowers authors in the development of manuscripts with persuasive rhetoric. Unfortunately, the use of common language has the potential to simultaneously facilitate the consumption of technical information and slows scientific progress through the use of ambiguous terms. To be clear, although the use of common language facilitates discussion, it may concurrently limit scientific knowledge by unintentionally encouraging inappropriate inter-study comparisons. As we continue to explore how best to produce low-cost and readily available measures of sub-clinical physical capacity in population studies (21), efforts should continue to use existing data sources and to provide more precise labels of physical function.

Author Contribution: CS had the original idea and completed the first draft of the manuscript after completing data analysis. ANL significantly improved the draft by framing the discussion and focusing the goals of the project. Both CS and ANL were fully involved in the study and preparation of the manuscript. The material within our manuscript has not been and will not be submitted for publication elsewhere.

Conflict of Interest: Neither CS nor ANL have any conflict of interest with JARCP.

Funding: CS was supported by the NIH grant number U01 AG023744.

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