The effect of a breakfast program on nutritional status, quality of life, and health care use among frail homebound older adults

The population of older adults is rapidly increasing, creating a need for community services that assist vulnerable older adults in maintaining independence and quality of life. Recent evidence confirms the importance of food and nutrition in reaching this objective. The Elderly Nutrition Program (ENP) is part of a system of federally funded community based programs, authorized through the Older Americans Act. ENP services include the home-delivered meals program, which targets frail homebound older adults at nutritional risk. Traditionally, ENP services provide a noon meal 5 days/week. This study evaluated the impact of expanding the home-delivered meals service to include breakfast + lunch, on the nutritional status, quality of life and health care utilization of program participants. ^ This cross-sectional study compared 2 groups. The Breakfast group (n = 167) received a home-delivered breakfast + lunch, 5 days/week. The Comparison group (n = 214) received lunch 5 days/week. Participants, recruited from 5 ENP programs, formed a geographically, racially/ethnically diverse sample. Participants ranged in age from 60–100 years, they were functionally limited, at high nutritional risk, low income, and they lived alone and had difficulty shopping or preparing food. Participant data were collected through in-home interviews and program records. A 24-hour food recall and information on participant demographics, malnutrition risk, functional status, health care use, and applicable quality of life factors were obtained. Service and cost data were collected from program administrators. ^ Breakfast group participants had greater energy/nutrient intakes (p < .05), fewer health care contacts (p < .05), and greater quality of life measured as food security (p < .05) and fewer depressive symptoms (p < .05), than comparison group participants. These benefits were achieved for $1.30/person/day. ^ The study identified links from improvements in nutritional status to enhanced quality of life to diminished health care utilization and expenditures. A model of health, loneliness, food enjoyment, food insecurity, and depression as factors contributing to quality of life for this population, was proposed and tested (p < .01). ^ The breakfast service is an inexpensive addition to traditional home-delivered meals services and can improve the lives of frail homebound older adults. Agencies should be encouraged to expand meals programs to include a breakfast service. ^

The effect of osteoporosis education on calcium intake and physical activity in a group of community-dwelling Black older adults

The unprecedented increase in the number of older adults is expected to increase the burden of osteoporosis on the individual and society. Blacks have been understudied in osteoporosis prevention education research. Although the risk of osteoporosis is low in this population, its consequences are significant. This study employs a two-group experimental design (experimental and wait-list control groups) to evaluate the effect of an osteoporosis education on two osteoporosis prevention behaviors (OPBs)—calcium intake (CI) and physical activity (PA), in a group of community-dwelling Black older adults, 50 years and older resident in South Florida. A final sample of 110 (mean age 70.15 years), 90% female and 10% male completed a battery of questionnaires at two assessment periods. The experimental group participated in six weekly education program sessions immediately following baseline assessment, and the wait-list control group received the education following end of program assessment by all participants. The weekly educational sessions were conducted in social settings (church or senior center) employing constructs of the Revised Health Belief Model. The sessions focused on improving CI; osteoporosis knowledge (OKT), self-efficacy (SE), health beliefs (HB) and PA. Findings revealed significantly greater increase in reported CI ( M = 556 mg, Wilks’ λ = .47, F (1,108)=122.97, p< .001, η2=.53), OKT (p< .001), and SE (p< .001) among participants in the experimental compared to the wait-list control group. There was no significant difference between the two groups for PA and most of the HB subscales. OKT and SE were the best predictors of CI, while perceived barrier was a predominant factor predicting PA. Over the study period, a change in SE was the only variable related to changes in both OPBs. Attrition rate was lower than expected, which can be attributed to the settings utilized for the study. These findings support the importance of utilizing a familiar social setting. These results suggested the effectiveness of a program offered in multiple short sessions among this underserved minority population to improve OKT and SE resulting in a change in OPBs (increase in CI). However, there is need to explore alternative strategies to improve PA in this population group.

The Effect of Osteoporosis Education on Calcium Intake and Physical Activity in a Group of Community-Dwelling Black Older Adults

The unprecedented increase in the number of older adults is expected to increase the burden of osteoporosis on the individual and society. Blacks have been understudied in osteoporosis prevention education research. Although the risk of osteoporosis is low in this population, its consequences are significant. This study employs a two-group experimental design (experimental and wait-list control groups) to evaluate the effect of an osteoporosis education on two osteoporosis prevention behaviors (OPBs) – calcium intake (CI) and physical activity (PA), in a group of community-dwelling Black older adults, 50 years and older resident in South Florida. A final sample of 110 (mean age 70.15 years), 90% female and 10% male completed a battery of questionnaires at two assessment periods. The experimental group participated in six weekly education program sessions immediately following baseline assessment, and the wait-list control group received the education following end of program assessment by all participants. The weekly educational sessions were conducted in social settings (church or senior center) employing constructs of the Revised Health Belief Model. The sessions focused on improving CI; osteoporosis knowledge (OKT), self-efficacy (SE), health beliefs (HB) and PA. Findings revealed significantly greater increase in reported CI (M = 556 mg, Wilks’ λ = .47, F(1,108)=122.97, p< .001, η2=.53), OKT (p< .001), and SE (p< .001) among participants in the experimental compared to the wait-list control group. There was no significant difference between the two groups for PA and most of the HB subscales. OKT and SE were the best predictors of CI, while perceived barrier was a predominant factor predicting PA. Over the study period, a change in SE was the only variable related to changes in both OPBs. Attrition rate was lower than expected, which can be attributed to the settings utilized for the study. These findings support the importance of utilizing a familiar social setting. These results suggested the effectiveness of a program offered in multiple short sessions among this underserved minority population to improve OKT and SE resulting in a change in OPBs (increase in CI). However, there is need to explore alternative strategies to improve PA in this population group.

Assessment of nutritional status of patients on hemodilaysis: a single center study from Jeddah, Saudi Arabia.

Malnutrition (MN) is prevalent worldwide in hemodialysis patients (HDP); however it has not been assessed in HDP living in Jeddah, Saudi Arabia. The purpose of this study was to estimate the prevalence of MN in HDP at the Jeddah Kidney Center as well as to determine if the 7-point subjective global assessment (SGA) correlates with anthropometric [Body Mass Index (BMI), Tricep Skinfold Thickness (TSF), Mid-Arm Muscle Circumference (MAMC)], or biochemical (albumin) measurements. In a cross sectional, descriptive study, 270 HDP were assessed for MN. Over half of the HDP were malnourished, with 47.8% moderately and 6.3% severely malnourished. Fifty-eight percent of HDP did not adhere to their diet prescription. As albumin, BMI, TSF, and MAMC decreased, malnutrition became more severe (p < .01). Patients who were female (OR=.43, p=.001), older (OR=.45, p=.001), with no education (OR=3.10, p=.001), underweight (OR=3.56, p<.001), small TSF (OR=1.12, p=.001), and small MAMC (OR=1.15, p=.001) were more likely to be malnourished. The prevalence of MN is high in these HDP. A consistent nutritional assessment protocol is warranted and should be implemented to decrease MN in Saudi HDP.

Fear of Falling and Balance Confidence in Older Adults with Diabetes Mellitus

Several determinants of fear of falling (FoF) and low balance confidence overlap with the consequences/complications of diabetes mellitus (DM). FoF is strongly associated with low balance confidence, and balance confidence mediates the relationship between FoF and balance and physical function. The purpose of this thesis was two-fold: (1) to examine the prevalence, severity and determinants of FoF in older adults (aged≥65) with DM, and (2) to evaluate the validity of the short version of the Activities-specific Balance Confidence scale (ABC-6) and its association with balance and postural control in older adults with DM. Three separate studies were conducted of older adults with DM (DM-group) and without DM (noDM-group). Study I revealed that although FoF prevalence adjusted for age and sex was not different between-groups, the DM-group had 8.8% fewer participants in the low and 8.4% more in the high Falls-Efficacy Scale International categories when compared to the noDM-group. Higher FoF severity in the DM-group was associated with poor physical performance, being female, fall history and clinical depressive symptoms. Study II provided evidence of convergent, discriminant and concurrent validity of the ABC-6 for use in older adults with DM with and without diabetic peripheral neuropathy (DPN). Notably, the ABC-6 was more sensitive in detecting subtle differences in balance confidence between the DM-group and noDM-group when compared to the original ABC scale (ABC-16), and can be administered in less time. Study III explored balance confidence (ABC-6) and its association with balance and postural control in older adults with DM. Subtle differences in axial segmental control (i.e., lower trunk roll velocity and higher head-trunk correlations) while walking and lower balance confidence were apparent in the DM-group, even in the absence of DPN, when compared to the noDM-group. Balance confidence partially explained the variance in head-trunk stiffening between-groups, and consequently low balance confidence in older adults with DM may contribute to the dependence on postural control strategies that are normally only utilized in high-risk situations. Findings from this thesis will help to guide the development of protocols for screening and intervention recommendations of patient education and targeted rehabilitation programs for older adults with DM.

Falls and the Social Isolation of Older Adults in the National Health and Aging Trends Study

Thesis (Ph.D.)--University of Washington, 2016-08

Visual impairment, postural stability and falls among older adults with glaucoma

Purpose: To investigate the impact of glaucomatous visual impairment on postural sway and falls among older adults.Methods: The sample comprised 72 community-dwelling older adults with open-angle glaucoma, aged 74.0 5.8 years (range 62 to 90 years). Measures of visual function included binocular visual acuity (high-contrast), binocular contrast sensitivity (Pelli- Robson) and binocular visual fields (merged monocular HFA 24-2 SITA-Std). Postural stability was assessed under four conditions: eyes open and closed, on a firm and on a foam surface. Falls were monitored for six months with prospective falls diaries. Regression models, adjusting for age and gender, examined the association between vision measures and postural stability (linear regression) and the number of falls (negative binomial regression). Results: Greater visual field loss was significantly associated with poorer postural stability with eyes open, both on firm (r = 0.34, p < 0.01) and foam (r = 0.45, p < 0.001) surfaces. Eighteen (25 per cent) participants experienced at least one fall: 12 (17 per cent) participants fell only once and six (eight per cent) participants fell two or more times (up to five falls). Visual field loss was significantly associated with falling; the rate of falls doubled for every 10 dB reduction in field sensitivity (rate ratio = 1.08, 95% CI = 1.02–1.13). Importantly, in a model comprising upper and lower field sensitivity, only lower field loss was significantly associated with the number of falls (rate ratio = 1.17, 95% CI = 1.04–1.33). Conclusions: Binocular visual field loss was significantly associated with postural instability and falls among older adults with glaucoma. These findings provide valuable directions for developing falls risk assessment and falls prevention strategies for this population.

Telephone reliability of the Frenchay Activity Index and EQ-5D amongst older adults

Background Older adults may find it problematic to attend hospital appointments due to the difficulty associated with travelling to, within and from a hospital facility for the purpose of a face-to-face assessment. This study aims to investigate equivalence between telephone and face-to-face administration for the Frenchay Activities Index (FAI) and the Euroqol-5D (EQ-5D) generic health-related quality of life instrument amongst an older adult population. Methods Patients aged >65 (n = 53) who had been discharged to the community following an acute hospital admission underwent telephone administration of the FAI and EQ-5D instruments seven days prior to attending a hospital outpatient appointment where they completed a face-to-face administration of these instruments. Results Overall, 40 subjects' datasets were complete for both assessments and included in analysis. The FAI items had high levels of agreement between the two modes of administration (item kappa's ranged 0.73 to 1.00) as did the EQ-5D (item kappa's ranged 0.67–0.83). For the FAI, EQ-5D VAS and EQ-5D utility score, intraclass correlation coefficients were 0.94, 0.58 and 0.82 respectively with paired t-tests indicating no significant systematic difference (p = 0.100, p = 0.690 and p = 0.290 respectively). Conclusion Telephone administration of the FAI and EQ-5D instruments provides comparable results to face-to-face administration amongst older adults deemed to have cognitive functioning intact at a basic level, indicating that this is a suitable alternate approach for collection of this information.

Are Active Australia physical activity questions valid for older adults?

Objective The Active Australia Survey (AAS) is used for physical activity (PA) surveillance in the general Australian adult population, but its validity in older adults has not been evaluated. Our aim was to examine the convergent validity of the AAS questions in older adults. Design The AAS was validated against pedometer step counts as an objective measure of PA, self-reported physical function, and a step-test to assess cardiorespiratory fitness. Method Participants were community-dwelling adults, aged 65-89 y, with the ability to walk 100 m. They completed a self-administered AAS and the step-test in one interview. One week earlier, they completed the Short Form-36 physical function subscale. Between these two interviews, they each wore a YAMAX Digiwalker SW200 pedometer and recorded daily steps. Using the AAS data, daily walking minutes and total PA minutes (walking, moderate-intensity PA and vigorous-intensity PA) were compared with the validity measures using Spearman rank-order correlations. Fifty-three adults completed the study. Results Median daily walking minutes were 34.2 (interquartile range [IQR] 17.1, 60.0), and median daily total PA minutes were 68.6 (IQR 31.4, 113.6). Walking and total PA minutes were both moderately correlated with pedometer steps (Spearman correlation r=0.42, p=0.003, for each) but not with step-test seconds to completion (r=-0.11, p=0.44; r=-0.25, p=0.08, respectively). Total PA minutes were significantly correlated with physical function scores (r=0.39, p=0.004), but walking minutes were not (r=0.15, p=0.29). Conclusions This initial examination of the psychometric properties of the AAS for older adults suggests that this surveillance tool has acceptable convergent validity for ambulatory, community-dwelling older adults.

Simulated visual impairment leads to cognitive slowing in older adults

PURPOSE: To investigate the impact of different levels of simulated visual impairment on the cognitive test performance of older adults and to compare this with previous findings in younger adults. METHODS.: Cognitive performance was assessed in 30 visually normal, community-dwelling older adults (mean = 70.2 ± 3.9 years). Four standard cognitive tests were used including the Digit Symbol Substitution Test, Trail Making Tests A and B, and the Stroop Color Word Test under three visual conditions: normal baseline vision and two levels of cataract simulating filters (Vistech), which were administered in a random order. Distance high-contrast visual acuity and Pelli-Robson letter contrast sensitivity were also assessed for all three visual conditions. RESULTS.: Simulated cataract significantly impaired performance across all cognitive test performance measures. In addition, the impact of simulated cataract was significantly greater in this older cohort than in a younger cohort previously investigated. Individual differences in contrast sensitivity better predicted cognitive test performance than did visual acuity. CONCLUSIONS.: Visual impairment can lead to slowing of cognitive performance in older adults; these effects are greater than those observed in younger participants. This has important implications for neuropsychological testing of older populations who have a high prevalence of cataract.

Evidence of disagreement between patient-perceived change and conventional longitudinal evaluation of change in health-related quality of life among older adults

Objective: To identify agreement levels between conventional longitudinal evaluation of change (post–pre) and patient-perceived change (post–then test) in health-related quality of life. Design: A prospective cohort investigation with two assessment points (baseline and six-month follow-up) was implemented. Setting: Community rehabilitation setting. Subjects: Frail older adults accessing community-based rehabilitation services. Intervention: Nil as part of this investigation. Main measures: Conventional longitudinal change in health-related quality of life was considered the difference between standard EQ-5D assessments completed at baseline and follow-up. To evaluate patient-perceived change a ‘then test’ was also completed at the follow-up assessment. This required participants to report (from their current perspective) how they believe their health-related quality of life was at baseline (using the EQ-5D). Patient-perceived change was considered the difference between ‘then test’ and standard follow-up EQ-5D assessments. Results: The mean (SD) age of participants was 78.8 (7.3). Of the 70 participants 62 (89%) of data sets were complete and included in analysis. Agreement between conventional (post–pre) and patient-perceived (post–then test) change was low to moderate (EQ-5D utility intraclass correlation coefficient (ICC)¼0.41, EQ-5D visual analogue scale (VAS) ICC¼0.21). Neither approach inferred greater change than the other (utility P¼0.925, VAS P¼0.506). Mean (95% confidence interval (CI)) conventional change in EQ-5D utility and VAS were 0.140 (0.045,0.236) and 8.8 (3.3,14.3) respectively, while patient-perceived change was 0.147 (0.055,0.238) and 6.4 (1.7,11.1) respectively. Conclusions: Substantial disagreement exists between conventional longitudinal evaluation of change in health-related quality of life and patient-perceived change in health-related quality of life (as measured using a then test) within individuals.

Risk of falls, injurious falls, and other injuries resulting from visual impairment among older adults with age-related macular degeneration

Purpose: Age-related macular degeneration (AMD) is the leading cause of irreversible visual impairment among older adults. This study explored the relationship between AMD, falls risk and other injuries and identified visual risk factors for these adverse events. Methods: Participants included 76 community-dwelling individuals with a range of severity of AMD (mean age, 77.0±6.9 years). Baseline assessment included binocular visual acuity, contrast sensitivity and merged visual fields. Participants completed monthly falls and injury diaries for one year following the baseline assessment. Results: Overall, 74% of participants reported having either a fall, injurious fall or other injury. Fifty-four percent of participants reported a fall and 30% reported more than one fall; of the 102 falls reported, 63% resulted in an injury. Most occurred outdoors (52%), between late morning and late afternoon (61%) and when navigating on level ground (62%). The most common non-fall injuries were lacerations (36%) and collisions with an object (35%). Reduced contrast sensitivity and visual acuity were associated with increased fall rate, after controlling for age, gender, cognitive function, cataract severity and self-reported physical function. Reduced contrast sensitivity was the only significant predictor of falls and other injuries. Conclusion: Among older adults with AMD, increased visual impairment was significantly associated with an increased incidence of falls and other injuries. Reduced contrast sensitivity was significantly associated with increased rates of falls, injurious falls and injuries, while reduced visual acuity was only associated with increased falls risk. These findings have important implications for the assessment of visually impaired older adults.

Inferior field loss increases rate of falls in older adults with glaucoma

PURPOSE: To examine the visual predictors of falls and injurious falls among older adults with glaucoma. METHODS: Prospective falls data were collected for 71 community-dwelling adults with primary open-angle glaucoma, mean age 73.9 ± 5.7 years, for one year using monthly falls diaries. Baseline assessment of central visual function included high-contrast visual acuity and Pelli-Robson contrast sensitivity. Binocular integrated visual fields were derived from monocular Humphrey Field Analyser plots. Rate ratios (RR) for falls and injurious falls with 95% confidence intervals (CIs) were based on negative binomial regression models. RESULTS: During the one year follow-up, 31 (44%) participants experienced at least one fall and 22 (31%) experienced falls that resulted in an injury. Greater visual impairment was associated with increased falls rate, independent of age and gender. In a multivariate model, more extensive field loss in the inferior region was associated with higher rate of falls (RR 1.57, 95%CI 1.06, 2.32) and falls with injury (RR 1.80, 95%CI 1.12, 2.98), adjusted for all other vision measures and potential confounding factors. Visual acuity, contrast sensitivity, and superior field loss were not associated with the rate of falls; topical beta-blocker use was also not associated with increased falls risk. CONCLUSIONS: Falls are common among older adults with glaucoma and occur more frequently in those with greater visual impairment, particularly in the inferior field region. This finding highlights the importance of the inferior visual field region in falls risk and assists in identifying older adults with glaucoma at risk of future falls, for whom potential interventions should be targeted. KEY WORDS: glaucoma, visual field, visual impairment, falls, injury

Does metabolic compensation explain the majority of less-than-expected weight loss in obese adults during a short-term severe diet and exercise intervention?

Objective: We investigated to what extent changes in metabolic rate and composition of weight loss explained the less-than-expected weight loss in obese men and women during a diet-plus-exercise intervention. Design: 16 obese men and women (41 ± 9 years; BMI 39 ± 6 kg/m2) were investigated in energy balance before, after and twice during a 12-week VLED (565–650 kcal/day) plus exercise (aerobic plus resistance training) intervention. The relative energy deficit (EDef) from baseline requirements was severe (74-87%). Body composition was measured by deuterium dilution and DXA and resting metabolic rate (RMR) by indirect calorimetry. Fat mass (FM) and fat-free mass (FFM) were converted into energy equivalents using constants: 9.45 kcal/gFM and 1.13 kcal/gFFM. Predicted weight loss was calculated from the energy deficit using the '7700 kcal/kg rule'. Results: Changes in weight (-18.6 ± 5.0 kg), FM (-15.5 ± 4.3 kg), and FFM (-3.1 ± 1.9 kg) did not differ between genders. Measured weight loss was on average 67% of the predicted value, but ranged from 39 to 94%. Relative EDef was correlated with the decrease in RMR (R=0.70, P<0.01) and the decrease in RMR correlated with the difference between actual and expected weight loss (R=0.51, P<0.01). Changes in metabolic rate explained on average 67% of the less-than-expected weight loss, and variability in the proportion of weight lost as FM accounted for a further 5%. On average, after adjustment for changes in metabolic rate and body composition of weight lost, actual weight loss reached 90% of predicted values. Conclusion: Although weight loss was 33% lower than predicted at baseline from standard energy equivalents, the majority of this differential was explained by physiological variables. While lower-than-expected weight loss is often attributed to incomplete adherence to prescribed interventions, the influence of baseline calculation errors and metabolic down-regulation should not be discounted.