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BACKGROUND Understanding fall circumstances can help researchers better identify causes of falls and develop effective and tailored fall prevention programs. This study aims to describe fall circumstances among older adults from quantitative data using conventional statistical approaches and qualitative analyses using a machine learning approach. METHODS The MOBILIZE Boston Study enrolled 765 community-dwelling adults aged 70 years and older in Boston, Massachusetts. Occurrence and circumstances of falls (i.e., locations, activities, and self-reported causes of falls) were recorded using monthly fall calendar postcards and fall follow-up interviews with open- and close-ended questions during a 4-year period. Descriptive analyses were used to summarize circumstances of falls. Natural language processing was used to analyze narrative responses from open-ended questions. Results During the 4-year follow up, 490 participants (64%) had at least one fall. Among 1,829 falls, 965 falls occurred indoors and 804 falls occurred outdoors. Commonly reported activities when the fall occurred were walking (915, 50.0%), standing (175, 9.6%), and going down stairs (125, 6.8%). The most commonly reported causes of falls were slip or trip (943, 51.6%) and inappropriate footwear (444, 24.3%). Using qualitative data, we extracted more detailed information on locations and activities, and additional information on obstacles related to falls and commonly reported scenarios such as “lost my balance and fell”. conclusions Self-reported fall circumstances provide important information on both intrinsic and extrinsic factors contributing to falls. Future studies are warranted to replicate our findings and optimize approaches to analyzing narrative data on fall circumstances in older adults.

Background Cardiovascular disease (CVD) risk factors are transmitted from parents to children. We prospectively examined the association between parental cardiovascular health (CVH) and time to onset of CVD in the offspring. Methods and results The study consisted of a total of 5967 offspring–mother–father trios derived from the Framingham Heart Study. Cardiovascular health score was defined using the seven American Heart Association’s CVH metrics attained at ideal levels: poor (0–2), intermediate (3–4), and ideal CVH (5–7). Multivariable-adjusted Cox proportional hazards regression models, Kaplan–Meier plots, and Irwin’s restricted mean were used to examine the association and sex-specific differences between parental CVH and offspring’s CVD-free survival. In a total of 71 974 person-years of follow-up among the offspring, 718 incident CVD events occurred. The overall CVD incidence rate was 10 per 1000 person-years [95% confidence interval (CI) 9.3–10.7]. Offspring of mothers with ideal CVH lived 9 more years free of CVD than offspring of mothers with poor CVH (P Conclusions We found that offspring of parents with ideal CVH had a greater CVD-free survival. Maternal CVH was a more robust predictor of offspring’s CVD-free survival than paternal CVH, underscoring the need for clinical and policy interventions that involve mothers to break the intergenerational cycle of CVD-related morbidity and mortality.

Background Chronic pain is a risk factor contributing to mobility impairment and falls in older adults. Little is known about the patterns of circumstances of falls among older adults with chronicpain. Objective To examine the relationship between chronic pain and circumstances of falls including location, activities at the time of falls and self-reported causes of falls in older adults. Design Prospective cohort study. Setting Communities in/around Boston, Massachusetts. Subjects The MOBILIZE Boston Study enrolled 765 adults aged ≥70 years. Methods Pain severity, fall occurrence and fall circumstances were recorded using monthly calendar postcards and fall follow-up interviews during a 4-year follow-up period. Generalised estimating equation models were performed to examine the relation between monthly pain ratings and circumstances of the first fall in the subsequent month. Results Compared to fallers without chronic pain, fallers with moderate-to-severe pain had around twice the likelihood of reporting indoor falls (aOR = 1.93, 95%CI: 1.32–2.83), falls in living or dining rooms (aOR = 2.06, 95%CI: 1.27–3.36), and falls due to health problems (aOR = 2.08, 95%CI: 1.16–3.74) or feeling dizzy or faint (aOR = 2.10, 95%CI: 1.08–4.11), but they were less likely to report falls while going down stairs (aOR = 0.48, 95%CI: 0.27–0.87) or falls due to a slip or trip (aOR = 0.67, 95%CI: 0.47–0.95) in the subsequent month. Conclusions Given the exploratory nature of the study, these findings should be interpreted with caution. Future studies may investigate whether better pain management and tailored fall prevention in older people with chronic pain could lead to fewer falls.

Evidence suggests that the practice of sharing clinicians’ notes with patients via online patient portals may increase patient engagement and improve patient–clinician relationships while requiring little change in providers’ workflow. Authors examined clinical social workers’ experiences and attitudes related to open psychotherapy notes using focus groups and telephone interviews. Twenty-four of 29 eligible therapists agreed to open their notes to patients, and nine participated in this study. Participants were generally positive about their experiences and reported few disruptions to their workload or practice. However, they were hesitant to bring up notes to patients during sessions, and they discussed the benefits of open therapy notes mostly hypothetically. The five therapists who did not share notes worried that open notes would be detrimental to therapeutic relationships, patient well-being, and workflow. However, the concern they discussed most often related to the electronic health record rather than to open notes, because therapy notes are visible to all authorized clinicians as part of the general medical record. Future research is needed to deepen our understanding of the risks and benefits of open psychotherapy notes and to inform development of training programs to support therapists in opening notes.

Background Neuromuscular and clinical factors contribute to falls among older adults, yet the interrelated nature of these factors is not well understood. We investigated the relationships between these factors and how they contribute to falls, which may help optimize fall risk assessment and prevention. Methods A total of 365 primary care patients (age = 77 ± 7, 67% female) were included from the Boston Rehabilitative Impairment Study of the Elderly. Neuromuscular measures included leg strength and leg velocity, trunk extensor endurance, and knee range of motion. Clinical measures included memory, executive function, depressive symptoms, pain, sensory loss, vision, comorbidity, physical activity, mobility self-efficacy, and psychiatric medication. Factor analysis was used to evaluate clustering of factors. Negative binomial regression assessed the relationship of factors with three-year fall rate. Interactions were tested to examine whether clinical factors modified the relationship between neuromuscular factors and falls. Results Three factors emerged: (i) neuromuscular factors, pain, and self-efficacy; (ii) memory; and (iii) executive function. Having three neuromuscular impairments predicted higher fall rate (incidence rate ratio [95% confidence interval]: 3.39 [1.82–6.32]) but was attenuated by memory (1.69 [1.10–2.61]), mobility self-efficacy (0.99 [0.98–0.99]), psychiatric medication use (1.54 [1.10–2.14]), and pain (1.13 [1.04–1.23]). Pain modified the relationship between neuromuscular impairment burden (number of neuromuscular impairments) and falls. Having three neuromuscular impairments was associated with a higher fall rate in patients with high levels of pain (5.73 [2.46–13.34]) but not among those with low pain. Conclusions Neuromuscular impairment burden was strongly associated with fall rate in older adults with pain. These factors should be considered together during fall risk assessment, post fall assessment, and prevention.

Background This study aims to test whether persistent pain quality is associated with incident or worsening disability in four domains: mobility, activity of daily living (ADL) and instrumental activity of daily living (IADL) difficulty, and physical performance. Methods From the MOBILIZE Boston Study, a population-based cohort of adults aged ≥70 years, we studied participants with chronic pain who endorsed at least one pain quality descriptor (N = 398) and completed baseline and 18-month assessments. Pain quality was assessed using an adapted short-form McGill Pain Questionnaire with 20 pain quality descriptors in three categories: sensory, cognitive/affective, neuropathic. Persistence was defined as endorsing the same category at baseline and 18 months. Self-reported outcomes included mobility, ADL, and IADL difficulty. Physical performance was assessed using the short physical performance battery. Results After adjusting for baseline pain severity and other covariates, individuals with three persistent categories had a greater risk of developing new or worsening IADL difficulty relative to those with one persistent category (relative risk [RR] 2.69, 95% confidence interval [CI] 1.34, 7.79). Similar results were observed for ADL difficulty (RR 5.83, 95% CI 1.32, 25.85), but no differences were noted in risk for mobility difficulty. There was no significant linear trend in physical performance over 18 months according to number of persistent categories (p =.68). Conclusion Elders with persistent pain quality experienced a higher risk of developing new or worsening IADL and ADL disability with each additional category but not mobility difficulty or poorer physical performance. Longitudinal assessment of pain quality could be useful in determining risk for global disability among elders with chronic pain.

Almost half of older adults experience multisite musculoskeletal pain (MMP) contributing to difficulty in daily activities but little is known about specific domains by which pain interferes in daily living. This study aims to determine domains of pain interference (PI) related to MMP in a cohort of older adults living in the community. The MOBILIZE Boston Study (MBS) is a cohort study of 749 adults aged ≥70y. Musculoskeletal (MSK) pain was assessed using the joint pain questionnaire and grouped as: no pain, single site, and multisite pain. The Brief Pain Inventory PI sub-scale assessed level of interference (0-10 rating) in 7 categories in the previous week including general activity, mood, walking, work, relationships with people, sleep, and enjoyment of life. Interference items were grouped as: none (0 rating), mild (>0, ≤2), moderate ( ≥2, ≤5), and severe (≥5) PI. There was a strong gradient of PI according to pain groups with severe walking interference in 36.5% of those with MMP compared to 3.8% of those with no MSK pain. The least PI was in relationships with others (9.1% of MMP vs 1.1% of no MSK pain). Reports of interference in other domains were intermediate (20-26% of MMP vs 3-4% of no MSK pain). Women and those with Less education reported the most PI in every domain but no differences were observed by age. Greater attention to specific domains of pain interference such as walking could have substantial benefits for reducing the overall impact of MMP among older adults.

Background: Access to online patient portals is key to improving care, but we have limited understanding of patient perceptions of online portals and the characteristics of people who use them. Methods: Using a national survey of 3677 respondents, we describe perceptions and utilization of online personal health information (PHI) portals. Results: Most respondents (92%) considered online PHI access important, yet only 34% were offered access to online PHI by a health care provider, and just 28% accessed online PHI in the past year. While there were no differences across race or ethnicity in importance of access, black and Hispanic respondents were significantly less likely to be offered access (P = .006 and Conclusion: Health care providers are crucial to the adoption and use of online patient portals and should be encouraged to offer consistent access regardless of patient race and ethnicity.

Background Pain related to many age-related chronic conditions is a burdensome problem in elderly adults and may also interfere with cognitive functioning. The purpose of this study was to examine the cross-sectional relationship between measures of pain severity and pain interference and cognitive performance in community-living older adults. Methods We studied 765 participants in the Maintenance of Balance Independent Living Intellect and Zest (MOBILIZE) Boston Study, a population-based study of persons aged 70 and older. Global pain severity and interference were measured using the Brief Pain Inventory subscales. The neuropsychological battery included measures of attentional capacity (Trail Making Test A, WORLD Test), executive function (Trail Making Test B and Delta, Clock-in-a-Box, Letter Fluency), memory (Hopkins Verbal Learning Test), and a global composite measure of cognitive function. Multivariable linear regression models were used to analyze the relationship between pain and cognitive functioning. Results Elderly adults with more severe pain or more pain interference had poorer performance on memory tests and executive functioning compared to elders with none or less pain. Pain interference was also associated with impaired attentional capacity. Additional adjustment for chronic conditions, behaviors, and psychiatric medication resulted in attenuation of many of the observed associations. However, the association between pain interference and general cognitive function persisted. Conclusions Our findings point to the need for further research to understand how chronic pain may contribute to decline in cognitive function and to determine strategies that may help in preventing or managing these potential consequences of pain on cognitive function in older adults.

The prevalence of mild cognitive impairment (MCI) and mobility limitations is high among older adults. The aim of this study was to investigate the association between MCI status and both performance-based and self-report measures of mobility in community-dwelling older adults.An analysis was conducted on baseline data from the Boston Rehabilitative Impairment Study in the Elderly study, a cohort study of 430 primary care patients aged 65 or older. Neuropsychological tests identified participants with MCI and further subclassified those with impairment in memory domains (aMCI), nonmemory domains (naMCI), and multiple domains (mdMCI). Linear regression models were used to assess the association between MCI status and mobility performance in the Habitual Gait Speed, Figure of 8 Walk, Short Physical Performance Battery, and self-reported Late Life Function and Disability Instrument's Basic Lower Extremity and Advanced Lower Extremity function scales.Participants had a mean age of 76.6 years, and 42% were characterized with MCI. Participants with MCI performed significantly worse than participants without MCI (No-MCI) on all performance and self-report measures (p.01). All MCI subtypes performed significantly worse than No-MCI on all mobility measures (p.05) except for aMCI versus No-MCI on the Figure of 8 Walk (p = .054) and Basic Lower Extremity (p = .11). Moreover, compared with aMCI, mdMCI manifested worse performance on the Figure of 8 Walk and Short Physical Performance Battery, and naMCI manifested worse performance on Short Physical Performance Battery and Basic Lower Extremity.Among older community-dwelling primary care patients, performance on a broad range of mobility measures was worse among those with MCI, appearing poorest among those with nonmemory MCI.

Background No standard definition exists for the concept “persistent pain self-management” or how it should be defined in relation to older adults. Poorly defined concepts can result in misunderstandings in the clinical setting and can hinder research through difficulties identifying or measuring the concept. Objective To ascertain attributes, referents, antecedents, and consequences of the concept older adults' persistent pain self-management and develop a theoretical definition. Design Rodgers evolutionary model of concept analysis was used to systematically analyze articles from the academic and grey literature (N = 45). Data were extracted using standardized extraction forms and analyzed using thematic analysis. Findings This concept was discussed in three ways: as an intervention, in reference to everyday behaviors, and as an outcome. Five defining attributes were identified: multidimensional process, personal development, active individuals, symptom response, and symptom control. Patients' perceived need and ability to manage pain with support from others is necessary for pain self-management to occur. Numerous physical, psychological, and social health consequences were identified. A theoretical definition is discussed. Conclusions Our findings have clarified existing use and understanding regarding the concept of older adults' persistent pain self-management. We have identified three areas for future development: refinement of the attributes of this concept within the context of older adults, an exploration of how providers can overcome difficulties supporting older adults' persistent pain self-management, and a clarification of the overall theoretical framework of older adults' persistent pain self-management.

Chronic musculoskeletal pain is linked to increased fall risk among elders. Older adults with chronic pain also experience mobility limitations. This prospective study examined the mediating effect of gait measures in the relationship whereby pain leads to falls. In the MOBILIZE Boston Study II of adults aged ≥70y living in the Boston area, 294 completed the gait assessment. Chronic musculoskeletal pain was classified as multisite, single site, or no pain, based on pain assessment of the hand/wrists, shoulders, back, hip, knees and feet. The gait assessment included walking under each of 3 conditions, quiet walk (QW), easy dual task (DTE), and hard dual task (DTH), on a 16-foot sensored gait mat. Participants were instructed to subtract aloud from 100 by 5’s (DTE) and 3’s (DTH) while walking at a normal pace. Following baseline assessments of pain and gait, monthly fall calendars were collected over 2 years. Multivariable negative binomial models were performed to determine associations between pain and fall rates, adjusting for sociodemographic and health characteristics. Mediation effects of gait measures on the pain-fall relationship were evaluated using the Sobel test. Multisite pain was associated with a 51% increased risk of falls compared to no pain (adj. IRR=1.51, 95% CI: 1.51–2.10). A number of gait parameters mediated (p-value

Prevention of falls is a public health priority around the world. A key component in preventing falls is identification of factors that increase the risk of falls. Pain is a highly prevalent risk factor for falls and the role of cognition offers new avenues for investigation. Our symposium provides an epidemiologic perspective on the characteristics of pain and cognition and their role in the relation between pain and risk for falls. Dr. Manu Thakral will present a MOBILIZE Boston (MBS) I study on the relation between pain quality and risk for falls. Her work shows that those reporting cognitive/affective descriptors, i.e. miserable and unbearable, were at higher risk for falling than other descriptors. Dr. Suzanne Leveille will discuss persistent multi-site pain as a fall risk factor from the MBS II study. Her findings showed that attention mediated the pain-falls relationship in multi-site pain including measures of selective attention, visual attention and attentional switching. Dr. Kushang Patel will present longitudinal data from the National Health and Aging Trends Study on the risk of recurrent falls among elders with and without pain and dementia. His work showed that the risk for recurrent falls was almost 3 times higher for elders with pain and dementia compared to those without. Dr. Elizabeth Phelan will serve to discuss our findings in context of the state of the science on fall risk factors. Our findings have substantive implications for future pain management and fall prevention interventions which should consider cognitive factors in the experience of pain.

The relation between pain quality and fall risk is understudied. Understanding the role of pain quality in fall risk could inform tailored fall prevention interventions. A population-based sample of 560 elders in MOBILIZE Boston Study I selected pain qualities to describe how their pain may feel from 3 categories: cognitive/affective, sensory and neuropathic. Participants recorded falls on monthly calendars over 18 months. Rate ratios and 95% confidence intervals were estimated from negative binomial models predicting fall rate and adjusted for fall risk factors. Individuals reporting cognitive/affective descriptors had a 35% increased risk for falls (adj RR 1.35, 95% CI 1.01–1.79) similar to neuropathic descriptors. No statistically significant increased risk was associated with sensory descriptors. Individuals reporting 3 categories had a 47% increased risk for falls relative to 1 category (adj RR 1.47, 95% CI 1.04–2.06). Further study could elucidate whether pain management tailored for pain quality can reduce fall risk.

Chronic musculoskeletal pain (CMP) contributes to increased fall risk among older adults. Fall often occurs due to loss of standing balance. Standing postural control is “complex”, depending upon numerous inputs interacting across multiple temporal-spatial scales. The decreased complexity has been linked to increased fall risk. Pain may interfere with this metric of postural control, thus, lead to falls. The aim of this study is to determine whether CMP is associated with sway complexity in older adults. In the MOBILIZE Boston Study, 738 community-dwelling adults aged ≥70y completed a functional assessment, including eyes-open standing postural sway on a force plate. The degree of sway complexity was quantified using multiscale entropy. The Brief Pain Inventory and McGill Pain Map assessed global pain severity and pain locations, respectively. Relationships between pain and sway complexity were analyzed using multivariable Generalized Linear Models. More severe pain was significantly associated with peripheral neuropathy, impaired processing speed (Trail Making A (TMT-A)) and global cognitive function (Mini-Mental State Examination (MMSE). Those with moderate-to-severe pain had lower complexity compared to those with mild or no pain (p=0.01), adjusted for age, gender, education, neuropathy, and TMT-A or MMSE. Participants with lower leg pain had lower sway complexity than those without (p=0.01); no association between pain in other body sites and sway complexity were observed. CMP severity and lower leg pain are associated with decreased sway complexity in older adults. Future studies are needed to explore the underlying mechanisms through which the CMP affects sway complexity, thus, contributes to falls.

One in five elders in the U.S. are edentulous. Tooth loss and edentulism interfere with nutritional intake and quality of life. Although selected chronic diseases (e.g. diabetes) have been identified as possible risk factors for edentulism, data on multiple chronic conditions in relation to tooth loss is lacking. This study examined the association between major chronic conditions and tooth loss in the older US population. We performed a secondary data analysis 2012 Behavioral Risk Factor Surveillance System survey restricted to persons aged ≥65y. Tooth loss was categorized into four groups (no loss, lost 1–5 teeth, lost ≥6 teeth, and edentulous). Descriptive analysis and multinomial logistic regression were used. Sample weights were applied to derive population estimates. Among the 112,376 respondents, average age was 74y and 60% were women. We found that 27% reported no tooth loss and 15% were edentulous. Adjusted for sociodemographics and behavioral characteristics, chronic diseases associated with edentulism were: COPD (RR 1.95, 95%CI 1.68–2.26); cardiovascular disease (RR 1.44, 95%CI 1.26–1.64); arthritis (RR 1.31 95%CI 1.19–1.44); diabetes (RR1.14, 95%CI 1.02–1.28); and kidney disease (RR1.21, 95%CI 1.00–1.45). Cancer, stroke and asthma were not associated with edentulism. Also, older adults with two or more chronic diseases were more likely to have tooth loss (lost 1–5 teeth: OR1.12, 95%CI 1.04–1.19; lost≥6 teeth: OR 1.51, 95%CI 1.40–1.63); Edentulous: OR 1.54, 95%CI 1.40–1.68). Further research is needed to understand the relationship between chronic conditions and tooth loss in older adults. Interventions are needed to improve oral care and reduce risk for tooth loss.

Mobility limitations affect 25% of adults more than 65 years and impede walking and physical activity in this population (1). A number of studies suggest that limitations in mobility are of increasingly greater concern among elderly adults because this ability remains central to maintaining functional independence (2). Therefore, tools that allow for early screening of those at risk for decline in mobility and performance-based walking are indispensable for both geriatric research and clinical care (3). Key among these tools is habitual gait speed (HGS), a measure of straight-path walking, and a predictor of subsequent morbidity and mortality (4). Another important measure and a recently validated test of walking skill, the figure-of-8 walking test (F8WT), is theorized to more accurately assess walking during activities that require navigating around curved paths and avoiding obstacles (5). Some reports indicate that F8WT and HGS performance may be linked to tests of executive function (5). However, most of the studies evaluating the attributes that underlie walking performance have been completed among relatively small samples (N < 150 participants) and have not directly compared HGS and the F8WT across a wide array of attributes that may influence performance (6). Consequently, it remains unclear whether the two tests reflect different health attributes that underlie mobility limitations among community-dwelling older adults. We therefore sought to compare the physiologic, cognitive, and health attributes underlying performance of HGS and F8WT to better understand how the two tests contrast. Direct comparison of the two tests allows us to better understand the relationships among the attributes that influence mobility performance among elderly adults. To address this aim, we conducted an analysis of baseline data collected as part of the Boston Rehabilitative Impairment Study of the Elderly (Boston RISE). Boston RISE is a prospective cohort study among 430 primary care patients aged 65 and older, who are at risk for mobility decline and disability. Because F8WT consists of both curvilinear and straight patterns of walking, we expected that the Boston RISE study results would help delineate the contexts of care in which the respective walking tests would be most useful.

Tracking falls among elders is challenging. In this reliability study, which took place between October 2007 and February 2008, the authors compared participants’ daily recordings of falls on calendars with a telephone survey of recall of falls over the previous 3 months within the population-based MOBILIZE Boston Study cohort, a cohort of 765 elders. From the cohort, 218 participants were randomly selected. Falls were tracked prospectively on daily calendars (mailed back monthly). Telephone recalls of falls over the previous 3 months were conducted in January and February 2008. Agreement, sensitivity, and specificity were calculated to compare the occurrence of falls as determined by 3-month recall with falls recorded by daily calendar (gold standard) during the same 3-month period. Results showed good agreement between recall and calendars: 27 persons reported a fall by both methods. However, while the 3-month recall correctly classified persons who did not fall (164 persons by both methods), it missed 25% of participants who fell (of 36 participants with a calendar-reported fall, 9 did not report a fall by telephone recall). Kappa was 0.74 (95% confidence interval: 0.68, 0.80), sensitivity was 75%, and specificity was 96%. Retrospective 3-month recall of falls resulted in underreporting of falls by as much as 25% compared with daily calendars. Calendars should be considered the preferred method of ascertaining falls in longitudinal studies.

CHRONIC pain is a major cause of disability in older adults (1–3). Physical function is generally characterized by either self-reported problems or observed physical performance (4). These two types of assessments examine different though related dimensions of function because correlations between these measures are moderate at best (5). Interestingly, performance-based tests of lower extremity function predict adverse events in older persons, such as disability, falls, institutionalization, and death (6–8). Not surprisingly, use of these measures has been advocated as a clinical screening tool (5,7,8). An increasing number of studies investigate the relationship between pain and lower extremity function in older individuals. Most of these studies show that older adults with chronic pain in selected sites (eg, in the foot, knee, or lower back) show a variety of mobility-related impairments and limitations including decreased balance and gait speed (9–12). However, these results have not been entirely consistent (13). Few studies of older adults have compared specific measures of chronic pain such as number of pain locations or overall pain severity ratings, in relation to lower extremity function, and these studies used only self-reported measures of function (1,3,14). Results of studies investigating the relation between a selected pain characteristic and performance-based lower extremity function in older adults have been inconclusive. Although no significant association was reported, a study of well-functioning older persons found that adults who had back pain along with hip or knee pain had worse lower extremity performance compared with those with back pain alone (15). In a recent study of older community-dwelling Hispanics and non-Hispanic Whites, pain severity was not associated with lower extremity function (16). Inconsistencies in results may be explained by the use of different study cohorts and variations in pain measurement, for example, pain at selected sites, total number of pain sites, or pain severity. Clinical experience suggests that these latter two dimensions, which assess pain in general rather than at specific locations, may be more relevant to lower extremity function in older adults. Measures of pain interference that are sometimes used in clinical settings combine concepts of pain and its impact on function, precluding their use for studies examining the independent effects of pain on mobility in the population. Greater insight into which pain characteristics are associated with specific lower extremity functions may provide crucial information to improve assessment and management of chronic pain and its functional consequences in older adults. Therefore, the primary objective of the present study was to compare two measures of chronic pain, for example, number of pain sites and overall pain severity, in relation to lower extremity function in the older population.

Elevated homocysteine, causing tissue injury by such mechanisms as oxidative stress, endothelial damage, and protein homocysteinylation, is associated with multiple age-related problems including cardiovascular diseases, dementia, and osteoporotic fracture. Disability is one of the most common features in older adults. However, little is known about the role of homocysteine in physical disability among older adults.Participants (60 years, N = 1677) were from the National Health and Nutrition Examination Survey (NHANES) 1999-2002. Nineteen questionnaires in five major domains were administered to assess the level of difficulty in performing various tasks: activities of daily living (ADL), instrumental ADL (IADL), leisure and social activities (LSA), lower extremity mobility (LEM), and general physical activities (GPA). Peak quadriceps strength was obtained by using an isokinetic dynamometer. Habitual gait speed was obtained from a 20-foot timed walk. Homocysteine levels were measured by the Abbott homocysteine assay, an automated fluorescence polarization immunoassay (FPIA).Elevated homocysteine was associated with disability in ADL, IADL, LSA, and GPA after multivariate adjustment. The odds ratios (ORs) for disability in these domains comparing participants in the highest quartile of homocysteine to those in the lowest were 2.18 (95% confidence interval [CI], 1.32-3.59) for ADL; 1.62 (95% CI, 1.02-2.57) for IADL; 2.00 (95% CI, 1.14-3.51) for LSA; and 1.52 (95% CI, 1.05-2.21) for GPA. The strength of associations weakened somewhat after additional adjustment of quadriceps strength and/or gait speed, suggesting a mediating role of quadriceps strength and gait speed in the association between homocysteine and disability. Homocysteine had an inverse relationship to quadriceps strength and gait speed. Likewise, quadriceps strength seemed to mediate the inverse association between homocysteine and gait speed.Elevated homocysteine is associated with multiple domains of disability mediated in part by muscle strength and gait speed. The results suggest that homocysteine levels may be important indicators of performance status in older adults.

Chronic inflammation, measured by interleukin-6, predicts incident disability among elderly people. However, little is known about the relation of C-reactive protein (CRP) to disability.Participants (60 years old, N = 1680) were from the National Health and Nutrition Examination Survey 1999-2002. Disability in activities of daily living (ADL), instrumental activities of daily living (IADL), leisure and social activities (LSA), lower extremity mobility (LEM), and general physical activities (GPA) was obtained by self-report. Peak muscle power was the product of isokinetic peak leg torque and peak force velocity. Functional limitations were evaluated via habitual walking speed, which was obtained from a 20-foot timed walk. CRP levels were quantified by using latex-enhanced nephelometry.Elevated CRP levels were associated with disability in IADL, LSA, LEM, and GPA, independent of basic demographics, chronic medical diseases, health behaviors, as well as nutritional markers. The corresponding odds ratios of disability for each standard-deviation increase in natural-log-transformed CRP were 1.18 (95% confidence interval [CI], 1.02-1.35), 1.18 (95% CI, 1.00-1.39), 1.17 (95% CI, 1.03-1.33), and 1.17 (95% CI, 1.05-1.31), respectively. The relationship diminished after additional adjustment of leg power and/or walking speed, meaning that impairment in leg power and limitations in gait speed likely mediate the association between CRP and disability. CRP had an inverse relationship to leg power and walking speed. Likewise, additional adjustment for leg power substantially diminished the association between CRP and walking speed, suggesting a mediating effect of power between CRP and gait speed.Independent of chronic diseases, elevated CRP is associated with multiple domains of disability through mediation of muscle power, habitual gait speed, or both. Future research is needed to understand CRP as a risk factor for disability in older populations.

Background Refinement of the traditional task-based classification of disability is needed to advance the field of disability research and to inform clinical practice. We propose an enhancement of the taxonomy of disability that incorporates information about symptoms and impairments that directly contribute to disability. In the first step of this new development, we present evidence to support five categories of disability related to pain, balance, weakness, endurance, and other symptoms. Methods The Women's Health and Aging Study, begun in 1992, was a population-based study of older disabled women living in the Eastern region of Baltimore and surrounds. In-home examinations were conducted every 6 months for 3 years. During the second examination, the 879 participants were asked the main symptom cause of their disability for each activity with which they had difficulty. Symptom causes of disability in activities of daily living were grouped into five nonmutually exclusive categories as stated above. Descriptive analyses were used to compare groups according to sociodemographic, health, disease, and physical performance information. Results Women with pain-related disability were younger, more obese, and had high prevalence of widespread pain and symptomatic osteoarthritis. Balance-related disability was related to having an age of 85 years or older, being Caucasian, and poor performance in tests of standing balance and gait. Women with weakness-related disability were older, more often African American and sedentary, had high prevalence of stroke and diabetes, and performed poorly in chair-stands and knee strength tests. Endurance-related disability was associated with low self-rated energy, depressive symptoms, smoking history, and lung and cardiovascular diseases. Conclusions The proposed refinement of the taxonomy of disability describes a set of empirically derived symptom and impairment-related disability groupings that have criterion and face validity. Further research about symptom and impairment-related disability in other populations of older persons is warranted.

BACKGROUND In a clinical study evaluating the functioning of mobility-limited elders, muscle power accounted for more of the variation in function than strength did. There was also evidence that the power-function relationship may be described as curvilinear. However, these findings have never been confirmed in a representative population. METHODS An analysis was conducted using data from the InCHIANTI study, a population-based cohort of 1032 adults living in Italy. To assess the relationships between impairments in power and strength and mobility performance, we created separate multivariate linear and log-transformed regression models as well as separate logistic regression models. RESULTS Subjects were age > or = 65 years, predominantly female (54%), with a mean age of 74.2 years, and most had mild-moderate mobility limitations (Short Physical Performance Battery score 10.5 +/- 2.1). Though leg extension power and isometric hip extension strength were closely associated, in several separate multivariate linear regression models, leg power consistently explained more of the variance than strength did in several measures of physical performance. Differences were even larger when observed in curvilinear models of power and strength. Using separate multivariate logistic regression models to examine the odds ratios for mobility limitations in persons with low muscle power versus high muscle power, and in persons with low muscle strength versus high muscle strength, we found that both factors influenced risk for mobility limitations, but low power was associated with a 2-3-fold greater likelihood than low strength. CONCLUSION These findings identified muscle power to be a more influential proximal determinant of physical performance than impairments in strength and emphasized muscle power as an important determinant of mobility skills in older adults.

Cognitively stimulating activities can improve both cognitive and physical function. Foot reaction time, a test of neuromotor performance and a possible risk factor for falls in older adults, might be influenced by participation in cognitively stimulating activities. The aim of this cross-sectional study was to examine the association between cognitive leisure activities and foot reaction time. We studied 310 community-dwelling older adults aged 71 to 101 years (mean=84.0y), in the MOBILIZE Boston Study II. Simple foot reaction time (SRT) and choice foot reaction time (CRT) were measured as time to initiation of movement in response to an intermittent light stimulus, seated with feet placed on a gait mat (CIR Systems, Inc., Franklin, NJ). The Cognitive Activity Scale (CAS), assessed frequency of participation in 17 cognitive leisure activities. SRT and CRT ranged from 0.17 to 0.55ms (mean=0.25 ± 0.06ms), and 0.21 to 0.72ms (mean=0.32 ± 0.08ms), respectively. Average SRT and CRT were shorter according to higher CAS scores. In multivariable models adjusted for age, sex, race, education, mobility difficulty, peripheral arterial disease, and number of joint pain sites, CAS scores were associated with shorter SRT (p=0.02) and CRT (p=0.01). The association persisted but was weaker after further adjusting for gait speed (SRT, p=0.05; CRT, p=0.03). Adjustment for vision impairment did not alter the relationship between CAS and reaction time. These results show that participation in cognitively stimulating activities is associated with shorter foot reaction time. Further research is needed to determine whether participation in cognitive activities could reduce fall risk in older adults.

The identification of novel targets that are risk factors for mobility limitations may improve the ability to prevent and treat mobility impairments among older adults. We tested the hypothesis that impaired rhythmic interlimb ankle and shoulder coordination are risk factors for subsequent mobility limitations among older adults. We conducted a 1-year prospective cohort study of community-dwelling older adults (N = 99) aged ≥ 67 years who did not have mobility limitations (Short Physical Performance Battery score > 9) at baseline. Participants performed antiphase coordination of the right and left ankles or shoulders while paced by an auditory metronome. Using multivariable logistic regression, we determined odds ratios for mobility limitations at 1-year follow up as a function of coordination variability and asymmetry. Adjusting for age, sex, body mass index, Mini Mental-State Examination score, and number of chronic conditions, odds ratios were significant for developing mobility limitations associated with a 1 standard deviation difference in the variability of ankle (OR = 1.88; 95% CI: 1.16–3.05; P = 0.011) and shoulder (OR = 1.96; 95% CI: 1.18–3.26; P = 0.009) coordination. Odds ratios were significant for asymmetry of shoulder (OR = 2.08; 95% CI: 1.23–3.51; P = 0.006), but not ankle (OR = 0.96; 95% CI: 0.60–1.55; P = 0.870) coordination. The results support our hypothesis that impaired interlimb ankle and shoulder coordination are risk factors for the development of mobility limitations. These findings indicate that the treatment of impaired coordination may be a means for preventing mobility limitations among older adults.

Objectives Older people with less education have substantially higher prevalence rates of mobility disability. This study aimed to establish the relative contributions of incidence, recovery rates, and death to prevalence differences in mobility disability associated with educational status. Methods Data were from 3 sites of the Established Populations for Epidemiological Study of the Elderly, covering 8,871 people aged 65-84 years who were followed for up to 7 years. Participants were classified on years of education received and as disabled if they needed help or were unable to walk up or down stairs or walk half a mile. A Markov model computed relative risks, adjusting for the effects of repeated observations on the same individuals. Results Differences between education groups in person-years lived with disability were large. The relative risk of incident disability in men with 0-7 years of education (vs. those with 12 or more years) was 1.65 (95% CI = 1.37-1.97) and in women was 1.70 (95% CI = 1.15-2.53). Both recovery risks and risks of death in those with disability were not significantly different across education groups in either gender. Discussion Higher incidence of disability is the main contributor to the substantially higher prevalence of disability in older people of lower socioeconomic status. Efforts to reduce the disparity in disability rates by socioeconomic status in old age should focus mainly on preventing disability, because differences in the course of mobility disability after onset appear to play a limited role in the observed prevalence disparities.

Objectives. To better understand disablement and transitions from impairment to disability, discrete valid measures of functional limitation are needed. This study reports the development and criterion-related validity of scales that quantify severity of upper and lower extremity functional limitation. Methods. Data are from 3,635 cognitively intact community-dwelling women aged 65 years and older and 1,002 moderately to severely disabled participants in the Women’s Health and Aging Study. Scales assessing severity of upper and lower extremity functional limitation were constructed from commonly available questions on functional difficulty. Criterion-related validity was evaluated with self-report and performance-based measures. Results. The upper and lower extremity scales range from 0 to 6 and 0 to 9, respectively. Scale scores were well distributed in the disabled group and discriminated limitations in the broader community. For both scales, rates of difficulty for all ADL and IADL increased ( p , .001) with increasing severity score, and percent able and mean performance on respective upper and lower extremity tasks decreased ( p , .01).

Background. Despite the large burden of chronic disease in older persons, especially those with disability, little research has documented changes in symptomatology over short periods of time. Additionally, although it has been demonstrated that medical conditions strongly affect functional level, short-term worsening in condition status has not been investigated for its impact on functional change. Methods. In a substudy of the Women's Health and Aging Study, 102 women with mild to severe disability received weekly home visits over a 6-month period. Each week they were queried as to the onset of 14 acute, generally self-limited conditions and the worsening or new diagnosis of 12 chronic conditions (condition reporting). They also received: a battery of physical and cognitive performance tests. Results. There was a high rate of condition reporting over 24 weekly interviews. Nearly all women reported acute and episodic conditions; the average number of weeks of reporting one or more conditions was 11.8 per woman. For chronic conditions, the average number of weeks of reporting worsening of one or more conditions was 5.2 per woman. Multiple reports of onset or worsening of specific conditions were common, especially for arthritis of the hands, hips, knees, or feet; urinary problems; dizziness or unsteadiness on feet; and back pain. The total number of condition reports and number of weeks of condition reporting were generally not associated with an individual's slope of change in performance tests. For specific conditions, there were generally small and nonsignificant changes in performance in those who reported onset or worsening after 3 or more weeks of not reporting this. Conclusions. Older disabled women frequently report the onset or worsening of acute and chronic conditions. In weekly observations, these conditions are not related to changes in physical and cognitive performance measures. Possible reasons for this are that (a) condition reporting may not be valid, (b) changes or severity of conditions were of insufficient magnitude to affect functioning, or (c) performance measures are not sensitive to the kinds of changes in chronic and acute conditions that affect people from week to week. We concluded that performance measures are not useful in monitoring modest, short-term changes in health status, but may still be valuable for assessing more major changes in health and functioning over time.

The purpose of this study was to estimate the prevalence of having no disability in the year prior to death in very old age and to examine factors associated with this outcome. Participants were men and women aged 65 years and older who were followed prospectively between 1981 and 1991 from three communities: New Haven, Connecticut; Iowa and Washington counties, Iowa; and East Boston, Massachusetts. Persons who died in late old age with known disability status within 15 months of death (n = 1,097) were studied for predictors of dying without disability at the last follow-up interview prior to death. The probability of a nondisabled 65-year-old man's surviving to age 80 and then being nondisabled prior to death was 26% and, for a 65-year-old woman, the probability of surviving to age 85 and being nondisabled before death was 18%. Physical activity was a key factor predicting nondisability before death. There was nearly a twofold increased likelihood of dying without disability among the most physically active group compared with sedentary adults (adjusted odds ratio = 1.86, 95% confidence interval 1.24-2.79). These findings provide encouraging evidence that disability prior to death is not an inevitable part of a long life but may be prevented by moderate physical activity.

The effect of smoking and physical activity on active and disabled life expectancy was estimated using data from the Established Populations for Epidemiologic Studies of the Elderly (EPESE). Population-based samples of persons aged > or = 65 years from the East Boston, Massachusetts, New Haven, Connecticut, and Iowa sites of the EPESE were assessed at baseline between 1981 and 1983 and followed for mortality and disability over six annual follow-ups. A total of 8,604 persons without disability at baseline were classified as "ever" or "never" smokers and doing "low," "moderate," or "high" level physical activity. Active and disabled life expectancies were estimated using a Markov chain model. Compared with smokers, men and women nonsmokers survived 1.6-3.9 and 1.6-3.6 years longer, respectively, depending on level of physical activity. When smokers were disabled and close to death, most nonsmokers were still nondisabled. Physical activity, from low to moderate to high, was significantly associated with more years of life expectancy in both smokers (9.5, 10.5, 12.9 years in men and 11.1, 12.6, 15.3 years in women at age 65) and nonsmokers (11.0, 14.4, 16.2 years in men and 12.7, 16.2, 18.4 years in women at age 65). Higher physical activity was associated with fewer years of disability prior to death. These findings provide strong and explicit evidence that refraining from smoking and doing regular physical activity predict a long and healthy life.

In a study of the relation between foot pain and disability, a cross-sectional analysis was performed using baseline data (1992-1995) from the Women's Health and Aging Study, a population-based study of 1,002 disabled women aged 65 years and older living in Baltimore, Maryland. Chronic and severe foot pain, defined as pain lasting 1 month or longer in the previous year, plus pain in the previous month rated severe (7-10 on a scale of 0 to 10), was reported by 14% of the women. Severe foot pain was more common in women who were younger (aged 65-74 years), obese, or had hand or knee osteoarthritis. Walking speed and five repeated chair stands were slower in women with foot pain. After adjustment for age, body mass index, race, education, self-rated health, smoking status, comorbidities, and number of other pain sites, severe foot pain was independently associated with increased risk for walking difficulty (adjusted odds ratio = 1.69, 95% confidence interval 1.10-2.59) and disability in activities of daily living (adjusted odds ratio = 1.91, 95% confidence interval 1.21-3.01). These findings suggest that severe foot pain may play a key role in disability in older women. Further studies are warranted to confirm these results longitudinally and to determine whether interventions to alleviate foot pain could reduce or prevent disability in older women.

Background Because preventing functional decline in older adults is a national priority and senior centers have been identified as potentially important venues for health-promotion activities, a trial of a multicomponent disability prevention program was conducted at a senior center. Methods One hundred older adults were recruited for a 6-month randomized clinical trial. All members of the experimental group received an exercise intervention, nutrition counseling, and a home safety assessment. Smoking and alcohol interventions were delivered to at-risk subjects. Outcome variables included the Medical Outcomes Study Short Form (SF-36) health survey, the CES-Depression scale, bed days, and restricted-activity days. Results A single study announcement resulted in a response sufficient to recruit 100 subjects. The exercise program was well received: 85% of intervention subjects completed the 6-month program and adherence was excellent, with over 90% attendance at exercise classes. After 6 months the intervention group had significantly better scores on 7 of 8 SF-36 subscales and fewer depressive symptoms than controls. Conclusions Senior centers may be excellent sites for community-based health promotion interventions: participation and adherence rates may be acceptable, interventions can be designed that are feasible in this setting, and these interventions appear to affect health status positively. The study program improved physical and psychosocial functioning and is a promising model for preventing functional decline through activities based at senior centers.

The purpose of this article is to examine Black/White differences among older women in the relationship between physical functional difficulties and variations in cognitive status, measured within the low to high normal range of the Mini-Mental State Examination (MMSE). We studied 3,585 women with MMSE scores of 18 and above from a population-based random sample of 3,841 community-dwelling women aged 65 and older living in East Baltimore, Maryland. Trained interviewers administered the MMSE and obtained information on demographics, medical conditions, and functional difficulties. Prevalence of any functional difficulty was 43.3% in Whites and 48.5% in Blacks, who were 25% of the study sample. After adjusting for age and education, a significant trend for increasing functional difficulty with decreasing MMSE scores was found in White women but not in Black women. Since no explanation for these racial differences could be identified, these findings suggest that the MMSE may not be a valid predictor of functional difficulty in Black women who score > or = 18 on the instrument.