Optimizing functional status in older people

Overview

Introduction

Common problems in older age are characterized by difficulties with hearing, seeing, remembering, moving, or performing daily or social activities.[1] Preservation of function and independence is one of the goals of successful aging.[2] Functional status is measured by the ability of people to perform basic and instrumental activities of daily living (ADLs). Basic activities of daily living (BADLs) consist of self-care tasks and include feeding, bathing, dressing, using the toilet, personal hygiene, ability to transfer from bed to chair and back again, and walking.[3] Instrumental activities of daily living (IADLs) allow a person to live independently in a community. They include the ability to use the telephone, perform housework and laundry, shop, prepare meals, manage finances, take prescribed drugs, and arrange appropriate transportation.[4] More advanced ADLs include hobbies and leisure activities.

Information on functional status can be obtained during a patient interview and typically does not require a questionnaire.

Screening for geriatric syndromes helps to identify risk factors for and causes of functional impairment. Identification of such syndromes and initiation of appropriate assessment and management strategies may also foster preservation of function. Several validated screening tools have been published to screen for many of these syndromes:

Delirium: Confusion Assessment Method (CAM), Richmond Agitation Sedation Scale (RASS)
Dementia: Short Portable Mental Status Questionnaire, AD8, Mini-Cog
Depression: Geriatric Depression Scale, PHQ-9, Cornell Scale for Depression in Dementia
Malnutrition: Mini Nutritional Assessment (MNA)
Pain: Verbal Pain Descriptors, Pain Thermometer, Faces Scale for Pain
Falls: the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) Algorithm provides guidance on how to screen, evaluate, and intervene in persons at risk for falls.[5] Assessment tools include: Get-Up-and-Go (timed and modified), 30-Second Chair Stand, 4-Stage Balance tests, and Functional Reach.[6] [7] [8] [9] [10]

Functional decline in and of itself should not be considered a geriatric syndrome but rather an indicator of the negative impact that geriatric syndromes and acute/chronic medical conditions may have on an individual. Threats to functional independence arise from physical and cognitive limitations as a process of normal aging or the accumulation of chronic illness. Management of chronic illness is a key factor in preserving function. To optimize function as a result of the aging process, physical and cognitive interventions may be used when possible.[11] Counseling patients regarding exercise and following up with them regularly has been shown to have a positive effect on mobility and helps preserve independence in community-dwelling older people.[12] In one meta-analysis, participation in exercise was shown to increase gait speed, balance, and performance in ADLs in frail older adults.[13] Physical interventions include regular exercise, balance training, participation in resistance training (RT), and endurance training. Cognitive interventions include participating in leisure activities and in cognitively stimulating activities (cognitive training). Despite the focused nature of many of these activities, their benefits may overlap. For example, participating in cardiovascular physical activities may also benefit cognitive function. The evidence of the effectiveness of these interventions continues to improve over time. Aside from benefits of single interventions, evidence that multicomponent interventions to preserve function and independence (in one study, specifically looking at cognitive and physical interventions to reduce risk of dementia) continue to emerge.[14] [15] Given the potential benefit of preserving and optimizing the functional status of older people, risk in implementing these interventions more often than not is outweighed by the benefits. Guidelines supporting such interventions have been published.[16]

Frailty

Frailty is a syndrome clinically manifested by a combination of muscle mass loss, fatigue, slowness, and low level of physical activity. It is characterized by a decline in functional state across multiple physiologic systems.[17] This leads to a reduced ability to recover from acute stress.[18] Even a "minor" change such as a new drug, or something more major like an infection or surgery, can result in a disproportionate change in state of health, taking a person from being independent to dependent.[17]

Vulnerability of frail older people to a sudden change in health status following a minor illness. The green line represents a fit older person who, following a minor stress such as an infection, experiences a relatively small deterioration in function and then returns to homeostasis. The red line represents a frail older person who, following a similar stress, experiences a larger deterioration which may manifest as functional dependency and who does not return to baseline homeostasis

Clegg A et al. Lancet 2013 Mar 2;381(9868):752-62; used with permission

A number of different screening tools and criteria have been developed to identify frailty and assess severity.[19] Simple scales such as the FRAIL scale (Fatigue, Resistance, Ambulation, Illness, and Loss of weight) can be useful in identifying these individuals who are risk for disability over time.[20] Beyond physical frailty, cognitive impairment and its impact on function can also be used as a marker for frailty, specifically looking at how much functional impairment is attributable to the cognitive impairment/dementia itself.[21]

Clinical development of frailty syndrome typically occurs over time and can be a manifestation of multiple comorbidities, lifestyle choices, and environmental factors that lead to expression of the clinical phenotype of frailty syndrome. Risk factors for frailty include advanced age, polypharmacy, functional decline, poverty, isolation, poor nutrition, weight loss, medical comorbidity, and psychiatric comorbidity.[18] Living with frailty increases the risk of multiple adverse outcomes including falls, admission to hospital, and death.[22]

Undernutrition is associated with frailty, sarcopenia, and poor health outcomes.[17] Support patients with frailty to eat a diet sufficient in protein and energy. Resistance training has been shown to improve muscle function, muscle mass, power, and strength in older adults with frailty.[23] [24] Aerobic exercise, resistance training, and walking have been shown to reduce frailty and disability.[25]

There are bidirectional associations between frailty and dementia. There is an increased risk of frailty in people with dementia and an increased risk of dementia in people with frailty.[26] [27] Healthcare professionals should have a low threshold for suspecting cognitive decline as many people with dementia have learned to adapt to day-to-day social questions despite underlying cognitive deterioration.

The community geriatric assessment (CGA) is a holistic assessment that leads to the creation of a personalized care plan in a person with frailty. The assessment covers physical, psychologic, social, environmental, and functional domains, and includes a comprehensive drug review. Interventions are tailored to the specific needs of the person and can involve the full spectrum of the multidisciplinary team.[28] One Cochrane systematic review found evidence that older people with frailty who have a CGA in the community setting may have a reduced risk of unplanned hospital admission, although it found no evidence of any impact on mortality or chance of admission to a nursing home.[28] Another systematic review published subsequently found that community-based complex interventions, such as the CGA, increased the likelihood of people living at home, reduced mortality, enhanced cognitive function, and improved instrumental activities of daily living, but did not improve quality of life.[29]

Physical interventions

Regular exercise

Sedentary behavior has been shown to be harmful and is associated with increased risk of cardiovascular disease, reduced quality of life, and increased risk of nursing home admission.[30] [31] [32] [33] [34] Watching television for 7 or more hours of the day has been associated with higher risk of developing Alzheimer disease.[35] [36] This type of behavior has also been associated with hypertension, diabetes, obesity, and hyperlipidemia.[37] Reducing sedentary behavior and remaining physically active helps to modulate its detrimental effects.[31] [32] [38]

Conversely, participation in an exercise programme provides a number of benefits and should be regarded as a therapeutic agent.[31] [39] Maintaining or increasing cardiorespiratory fitness reduces the risk of hospital admission.[38] Exercise should be differentiated from being 'physically active' in that the energy expended to participate should be great enough to be effortful for the individual (e.g., feeling more short of breath while doing the exercise), though benefit exists for both being physically active and increasing this intensity for it to be considered exercise. Older adults should do multicomponent physical activity that includes balance training as well as aerobic and muscle-strengthening activities.[40]

Emerging data shows that being physically active throughout the day, even by walking on a regular basis, can preserve mobility.[41] The more steps that are taken during the daytime, the greater the benefit.[42] [43]

Increased physical activity has been associated with a reduced risk of dementia.[44] [45] Participation in higher levels of physical activity (reported as exercising 3 or more times a week at an intensity greater than walking) was associated with a lower risk of developing Alzheimer disease in 5 years when compared with no exercise.[46] [47] In patients with dementia, exercise programs with multiple components (e.g., gait, balance, strengthening) have been shown to preserve physical function and BADLs, regardless of the stage of the disease.[48] Improvements in balance and performance of ADLs have been seen in women participating in exercise programs.[49] [50]

Participating in physical activity has also been associated with positive impacts on mortality, with the greatest benefit achieved at high levels of activity.[51] [52] [53] In one study, men who maintained or improved levels of physical activity were less likely to die (from all causes and cardiovascular disease) than were unfit men.[54] Even when started later in life, physical activity can improve mortality.[54] For those challenged by significant physical activity, one study of older women showed that even walking 4400 steps daily was related to an improvement in survival.[55] Participation in structured physical activities may continue to provide benefits for up to 2 years after such activities have ceased.[56] [57] A study of disability rates showed that people who are physically active are more likely to die without a disability than are sedentary people.[58] This provides further support that physical activity and mobility training can preserve function.[59] [60] Research also suggests that any individual, regardless of their current level of function, can expect such participation to help preserve their current functional status and potentially reduce the risk of nursing home placement.[34] [61] [62] [63] [64] [65] These benefits occur regardless of whether activities take place at home or at a center where such activities are provided.[66]

The US Preventive Services Task Force (USPSTF) recommends exercise interventions to prevent falls in community-dwelling older adults ages 65 years and older who are at increased risk for falls.[67] Exercise interventions might include group exercise classes or supervised individual physical therapy.

Balance training

Impaired balance has been shown to increase the risk of falls, with an associated relative risk of 1.42 for falls in such individuals.[68] Studies of multi-component behavioral interventions have shown these to improve balance confidence.[69] Balance training and functional exercises have been shown to reduce the risk of falls by 7.2% in people at average and high risk of falls.[70] The exercise tai chi has been shown to be beneficial in reducing the risk of falls by improving balance.[71] Participating in these exercises for 15 weeks confers benefit.[72]

Resistance training (RT)

Several professional societies have provided specific recommendations for RT. The National Strength and Conditioning Association recommend that a properly designed RT program for older adults should include an individualized, periodized approach working toward 2 to 3 sets of 1 to 2 multijoint exercises per major muscle group, achieving intensities of 70% to 85% of 1 repetition maximum (1RM), 2 to 3 times per week, including power exercises performed at higher velocities in concentric movements with moderate intensities (i.e., 40% to 60% of 1RM). Furthermore, they state that RT programs for older adults should follow the principles of individualization, periodization, and progression. They note that it may be necessary to adapt programs for older adults with frailty, mobility limitations, cognitive impairment or other chronic conditions, and to accommodate older adults residing in assisted living and skilled nursing facilities.[73] The American Geriatrics Society has further classified the intensity of exercises. They define a maximum repetition as the maximum weight at which a particular exercise can be done only once (1 RM). They further define exercise as low (40% of 1 RM, performed 10 to 15 times), medium (40% to 60% of 1 RM, 8 to 10 repetitions), and high (>60% of 1 RM, 6 to 8 repetitions).[74] The American Heart Association (AHA) states that RT can slow the rate of aging-related declines in muscle mass, power, strength and function in healthy older adults and those with chronic conditions, but notes that only 19% of adults ages ≥65 years reported participating in RT ≥2 times per week.[23]

Gains have been reported over short periods of time. Meta-analysis evidence looking at the benefits of progressive resistance training has demonstrated its effectiveness in maintaining physical function in older individuals, particularly in strength and performance of simple and complex tasks.[75] [76] Muscle strengthening exercises have been associated with lower mortality associated with noncommunicable diseases such as cancer, diabetes, and cardiovascular diseases.[23][42][77] RT also improved walking endurance, walking speed, and dynamic balance, and reduced falls and falls related injuries in men and women.[23] [78] [79] [80] [81] [82] [83] Additionally, as low muscle mass and low muscle strength is associated with functional decline, preservation of both may be beneficial in preventing functional decline and preserving functional status.[84] However, longitudinal studies demonstrating sustained benefit are required. Continued participation in such exercises should be emphasized to maintain benefit.

The purpose of RT is to enhance muscle mass, strength, and endurance, and to have a positive effect on functional status and quality of life.[73] In older men, RT for at least 12 weeks has been shown to increase muscle mass and quality (defined as increased strength for the same amount of muscle mass).[85] In people with sarcopenia (loss of muscle mass related to aging), RT can increase muscle mass and quality.[86] The benefits tend to be less in women than in men, but muscle mass increases were not age dependent.[85] RT may maintain or increase basal metabolic rate, which may contribute to increased caloric expenditure when combined with aerobic exercise, and may lead to loss of body fat while body weight is preserved.[87] [88] [89] Bone mass remains unchanged or increases after applying substantial force.[90] This benefit is specific to bones related to the exercised muscle groups.[91] In a study of older patients in a nursing home who followed a 10-week program of RT, their increase in strength, gait velocity, and stair-climbing power was associated with an increase in their thigh muscle cross-sectional area.[78]

Endurance training

By increasing strength and stamina, the purpose of endurance training is to improve aerobic capacity (including associated cardiopulmonary and metabolic variables), reduce associated risk factors for cardiovascular disease, and promote cognitive health.[73] [92] [93] Reports of improved function after endurance exercises (e.g., walking or bicycling) leading to improved morbidity and mortality have been mixed.[94] In studies where function improved after endurance exercises, RT was also a component of the exercise program. Function improved most in the frailest people, while smaller improvements were noted in the more functionally intact, healthy older people.[78] [95]

Contraindications to resistance and endurance training

People with the following conditions should not undertake resistance or endurance training: unstable CHD; decompensated heart failure; uncontrolled arrhythmias; severe pulmonary hypertension (mean pulmonary arterial pressure >55 mmHg); severe and symptomatic aortic stenosis; acute myocarditis, endocarditis, or pericarditis; uncontrolled hypertension (>180/110 mmHg); aortic dissection; Marfan syndrome; and proliferative retinopathy, or moderate or severe nonproliferative diabetic retinopathy.[73]

People with the following conditions should be thoroughly evaluated before participating in endurance or RT: major risk factors for CHD; diabetes; uncontrolled hypertension (>160/>100 mmHg); low functional capacity (<4 metabolic equivalents [METs]); musculoskeletal limitations; and implanted pacemakers or defibrillators.[73] The MET of a task is a physiologic concept expressing the energy cost of a physical activity. One MET is defined as the resting metabolic rate obtained during quiet sitting.[74]

Cognitive interventions

Leisure activities

Observational studies have identified that leisure activities have a protective effect and are associated with a lower risk of developing dementia compared with not participating in these activities. People who frequently participated (i.e., several times a week) in leisure activities obtained more benefit than those who participated in activities rarely (i.e., up to once a week).[96] Leisure activities can be divided into cognitive and physical. Cognitive activities that have been found to confer protection include playing board games, reading, and playing a musical instrument. The only leisure physical activity that has been shown to confer protection is dancing.[97]

Cognitive stimulating activities and cognitive training

These seem to have positive benefits for preserving cognitive function in later life. Educational attainment is a factor associated with risk of dementia, with lower levels of education associated with a higher risk of developing dementia.[98] [99] In the US, attaining a high school education has been associated with maintaining cognitive function in late life.[100] The level of complexity of an occupation has also been associated with the level of intellectual functioning in late life.[101] The ability to maintain a ninth grade literacy level later in life has also been associated with maintenance of cognitive function.[100] There is emerging data linking participation in cognitive activity to brain structure. One study looking at this relationship demonstrated a potential protective effect of such activities in white matter microstructure.[102]

Activities specifically designed to improve cognitive function (cognitive training) have been studied longitudinally. A Cochrane meta-analysis of such interventions showed that overall they are successful in improving the cognitive areas that the interventions focus on during the period of the training, but clinical importance is uncertain, and duration of the benefits after the training period remain unclear.[103]

Despite these findings, there are some studies that have demonstrated some benefit. In one study, at the end of a 14-year period, a cohort of older people was divided into 2 groups: large or small decline in inductive reasoning or spatial cognition. They participated in 5 hours of activities related to inductive reasoning or spatial orientation training. Overall, 40% of those who showed substantial decline in these cognitive areas over the 14-year period returned to a level equivalent to their original performance following the 5-hour training activities.[104] Another prospective study assigned 2832 people aged 65 to 94 years to one of 4 different groups: 3 consisting of 10 sessions of group training in either verbal episodic memory, inductive reasoning, or speeded processing in a divided attention task, and a fourth no contact control group.[105] At 11 months, 60% of participants received 4 hours of booster training. Immediate benefits in the trained ability were noted and benefits were maintained over the 2 years of the study. It appears that focused cognitive training produces improvements or gains in cognition specifically in the areas that are trained, and the effects can be long-lasting, but these specific training exercises do not seem to affect normal daily activities.[106] More recent studies have demonstrated a positive effect on function. In one study of 908 community-dwelling older drivers who were randomized to 3 different forms of cognitive training (memory, reasoning, and speed of processing), the at-fault rate of motor-vehicle collision accidents was approximately 50% lower in the cohort of individuals randomized to the reasoning and speed of processing arms of the study compared with the controls.[107]

Beyond targeted cognitive training, functional task exercises have also been demonstrated to provide benefit in individuals with cognitive impairment. One trial looking at a 10-week trial of this intervention compared with cognitive training demonstrated significant difference in improvement in the functional task exercise program group compared with the cognitive training group in the areas of general cognitive functions, memory, executive function, functional status, and everyday problem-solving ability. These benefits were sustained at the 6-month follow-up period.[108]

It appears that cognitive interventions in the forms of focused cognitive training or exercises focusing on functional tasks can produce sustained improvements or gains in cognition and/or function.

Nutritional interventions

Nutrition, age-related physiological changes and health are often interconnected.[34] [109] The Mediterranean diet has been shown to help preserve heart health as well as brain health.[109] [110] [111] The "MIND" diet, which emphasizes natural plant-based foods, encourages consumption of berries and leafy greens, and limits animal foods and foods high in saturated fat, has been shown to reduce the risk of incident dementia.[111] [112] Diets that are high in fruit, vegetables, nuts, legumes, fish, and whole-fat dairy are associated with a lower incidence of cardiovascular disease and mortality.[113] There is some data showing that adequate nutritional status is important in preserving cognitive function and functional status.[114]

Nutritional interventions (in the form of amino acid supplementation) in combination with resistance training has been shown to be effective in reducing muscle mass loss - this adds to a body of evidence supporting the combination of nutritional interventions as well as exercise to prevent functional decline.[115] [116]

Routinely, assessment for malnutrition in older adults is recommended in order to identify an existing risk early.[61] [117] Weight loss in older adults is associated with a significant increase in all-cause mortality, cancer-related mortality, and cardiovascular disease-related mortality.[118] Monitoring for weight loss (and working this up when appropriate), and reviewing the quality of a person's diet (ensuring that a variety of different foods are being consumed, encouraging intake of a variety of fresh fruits and vegetables, food containing high fiber and whole grains, and proteins derived predominantly from nuts, fish, and chicken (reducing intake of red meat as much as possible) should be an important part of routine health care.[61]

Images

Vulnerability of frail older people to a sudden change in health status following a minor illness. The green line represents a fit older person who, following a minor stress such as an infection, experiences a relatively small deterioration in function and then returns to homeostasis. The red line represents a frail older person who, following a similar stress, experiences a larger deterioration which may manifest as functional dependency and who does not return to baseline homeostasis

Citations

Key Articles

American Geriatrics Society white paper on healthy aging. American Geriatrics Society. 2018 [internet publication].[Full Text]
Izquierdo M, Merchant RA, Morley JE, et al. International Exercise Recommendations in Older Adults (ICFSR): Expert Consensus Guidelines. J Nutr Health Aging. 2021;25(7):824-53.[Abstract][Full Text]
Saffel-Shrier S, Johnson MA, Francis SL. Position of the Academy of Nutrition and Dietetics and the Society for Nutrition Education and Behavior: food and nutrition programs for community-residing older adults. J Nutr Educ Behav. 2019 Jul-Aug;51(7):781-97.[Abstract][Full Text]
Fragala MS, Cadore EL, Dorgo S, et al. Resistance Training for Older Adults: Position Statement From the National Strength and Conditioning Association. J Strength Cond Res. 2019 Aug;33(8):2019-52.[Abstract][Full Text]
Gates NJ, Rutjes AW, Di Nisio M, et al. Computerised cognitive training for 12 or more weeks for maintaining cognitive function in cognitively healthy people in late life. Cochrane Database Syst Rev. 2020 Feb 27;2(2):CD012277.[Abstract][Full Text]

Other Online Resources

US Preventive Services Task Force: recommendations on preventive health care

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