Fitness+Testing+in+Elderly+Population

= = // “Those who think they have no time for exercise will sooner or later have to find time for illness” //  -Edward Stanley



**Physical Independence:** “having the physical capacity needed to perform common everyday activities on one’s own without additional assistance, activities such as simple housework, lifting and carrying objects, negotiating steps, and walking far enough to do one’s own shopping and errands” [1].

**Functional Fitness Performance:** “having the physiologic capacity to perform normal everyday activities safely and independently” [2].

Sedentary lifestyle among the elderly population is a major concern because it leads to decreased muscle strength/endurance, balance, cardiovascular output, flexibility and overall decreased health. Due to the impairments caused by inactivity, this population is exerting max effort performing daily activities needed to keep their independence. These activities include climbing stairs, reaching in a cabinet, stepping off a curb, carrying groceries or standing from a chair. Quality of life is greatly impaired because of the energy expenditure needed for these functional activities. Most importantly, decreased health status increases fall risk among this population. One out of every three individuals over the age of 65 will fall each year making falls and fall related injuries the biggest factor contributing to hospitalizations, immobilization and loss of independence among this population [3]. Identifying patients at risk for falls and developing health deficits is important to keep these individuals functioning independently for as long as possible and increasing their quality of life.



**Our Purpose:** to identify physical fitness components influencing independence in elderly populations and identify appropriate tests to determine the fitness level needed to stay independent


 * Things to Consider When Choosing Assessment Tools: **


 * **The Purpose** - select a tool that will show the change you are observing
 * **Functional Mobility** - want to pick a test appropriate for your patients level and choose a test that will detect gradual changes (improvement/decline)
 * **Reliable** (produces similar scores from 1 test to another) /**Valid** (test measures what it’s intended to measure) for this population
 * **Feasibility** - length of test, cost, easy to administer, space etc
 * ** Performance Standards for Comparison **

[1]
 * = ** PHYSICAL PARAMETERS ** ||= ** FUNCTIONS ** ||= ** ADLS ** ||
 * = Muscle Strength/Endurance ||= Walking ||= Personal Care ||
 * = Aerobic Endurance ||= Stair Climb ||= Shopping/Errands ||
 * = Motor Ability (balance, power, speed/agility) ||= Lifting/reaching ||= Housework ||
 * = Flexibility ||= Bending/Kneeling ||= Gardening ||
 * = Body Comp ||= Jogging/Running ||= Sports ||
 * =  ||=   ||= Travel ||
 * = PHYSICAL   IMPAIRMENT  ||=  FUNCTIONAL   LIMITATION  ||=  REDUCED   ABILITY/DISABILITY  ||


 * Physical Fitness and Function: **
 * 1) ** Muscle strength/endurance **
 * Lower Extremity Strength is needed for climbing stairs, walking and standing from a chair.
 * Upper extremity strength is needed for household activities involving lifting such as cleaning and carrying groceries
 * 1) ** Aerobic endurance **
 * Needed for community ambulation, vacation, keeping up with grandkids
 * 1) ** Flexibility **
 * Affects posture
 * Helps normalize gait
 * Needed for getting in and out of car, brushing hair, putting clothes on
 * 1) ** Motor ability (power, speed/agility, balance) **
 * Important for safely getting up from a chair and going to the oven in a timely manner.
 * Important for walking on uneven surfaces/maneuvering around household objects (tables, dogs, rugs etc)
 * Decreasing fall risk
 * 1) **Body composition:**
 * Important for overall health status


 * Muscle strength/endurance **

// Five-Times-Sit-to-Stand Test (FTSST): // Evidence has shown that this test is a good measure lower extremity strength and balance in the elderly population. A test resulting in a slow time is associated with decreased lower extremity strength. Older adults who performed poorly on the sit-to-stand test have reported low physical activity levels and higher need of assistance in ADLs. Poor performance is also related to fall risk.

Although many individuals (25-30%) over 80 years of age are unable to perform 5 sit-to-stand repetitions. In this case, reference values have been established for the therapist to compare the individual’s performance to; 13.2 seconds for males and 14.4 seconds for females [4]

In Whitney et al. study [5]:
 * 93 subjects with balance disorders and 81 subjects without balance disorders
 * All subjects performed these 3 tests: FTSST, ABC, and DGI tests
 * FTSST has a sensitivity of 66% and specificity of 67%.
 * FTSST was correctly identifying subjects with a balance disorder 65%, but when combined with the ABC and DGI that percentage increased to 85%.

The FTSST is not the best indication of balance compared with other diagnostic tests, but this test is still useful for determining functional muscle strength in the elderly population [5].

[|__https://www.youtube.com/watch?v=4N4PhZlyYGM__]

// TEMPA: //

This test was developed to measure fine and gross dexterity, coordination, strength, endurance, ROM, and sensibility in the upper extremities of an elderly patient.

TEMPA consist of 9 tasks that replicate ADLs such as:
 * opening a jar
 * shuffling cards
 * opening a pill bottle
 * picking up a pitcher
 * pouring a glass of water



These tasks all require strength and precision to accomplish and are measured based on length of execution, functional rating, and task analysis.

In Nedelec et al. study:
 * Purpose was to determine normative values of TEMPA
 * 360 healthy community-dwelling subjects 60 years or older
 * Results:
 * length of execution increased with age
 * length of execution was also dependent on gender

There was not a correlation between endurance and accomplishment of tasks because all tasks are quick and are not repeated. While more studies should be performed to investigate the validity of the TEMPA, normative values for the test have been established for the therapist to determine normal results vs. strength deficits from aging [6].

// 6 Minute Walk Test: //
 * Aerobic Endurance **

Most activities of daily living involve some sort of ambulation. Many studies have been done to test the reliability as well as the validity of the test with patients who have different disorders. *Six minutes has been chosen as the time for the test because it has been proven to be a time-frame in which allow the test to be given to a wide spectrum of patients, compared to a distant constant test. *Simple and safe for patients.

Jones, C. J et al. * good test-retest reliability and to be sensitive to change by being able to detect across age and activity groups [7].
 * Purpose: Look at the effectiveness of the walk to measure physical endurance with a generally healthy population
 * Population: 77 volunteers (mean age of 73 years old)
 * Validity:
 * Determine correlation with previous scales (r=.96).
 * Comparing the scores to those from the treadmill test (r=.69).
 * Looking at the overall sensitivity of the test when it comes to functional ability by comparing the walk scores to self reported functional ability (R=.71)
 * Good indicator of overall physical functioning
 * Reliability: Looking at intraclass correlation between three trials.
 * Between trials 1 and 2 (.88< R < .94) and
 * Between Trials 2 and 3 (.91 < R < .97).

[|__https://www.youtube.com/watch?v=n-O8dHyYIF0__]

//Sit and reach://
 * Flexibility **

The standard for flexibility measurements of the hamstring is the sit in reach, which is done on the floor. However, this isn’t always feasible for the elderly population.
 * It is known that the standard sit and reach has high reliability and criterion validity.

Jones, C. J et al. *good intraclass test-retest reliability
 * Purpose: to test reliability and criterion validity in the chair sit-and-reach for elderly
 * 76 men and women
 * Reliability: tested on two different days, 2-5 days apart
 * R= .92 for men
 * R= . 96 for women

* CSR is reasonably accurate
 * Validity: Comparing standard SR and back saver SR to the CSR
 * Measured by passive range of a straight leg raise for hamstring tightness
 * SR: R = .76 for men; R= .81 for women
 * BSR: R = .7 for men; .71 for women

The chair sit and reach has overall been proven to be a good indicator, as well as more socially acceptable, of hamstring muscle flexibility in elderly populations [8].

[|__https://www.youtube.com/watch?v=RrgcDNpIxQ4__]


 * Motor ability (power, speed/agility, balance) **

// Berg Balance Scale //
 * Measures balance in older people by having patient perform a variety of tasks ranging from simple to more dynamic tasks
 * 14 components
 * [[image:http://synapse.koreamed.org/ArticleImage/1041ARM/arm-36-762-i001-l.jpg width="301" align="center"]]
 * 15-20 minutes to perform
 * Scoring ranges from 0-4. “0” indicates lowest level of function and “4” indicating highest level of function. Total score = 56
 * Interpretation:
 * 41-56 = low fall risk
 * 21-40 = medium fall risk
 * 0-20 = high fall risk


 * In case-control study, four functional tests were compared: Berg Balance Scale, Tinetti Mobility Score, Elderly Mobility Scale, and Timed Up and Go test
 * 17 single fallers, 22 multiple fallers, 39 without fall history (all older adults)
 * Mobility and balance assessment was performed for all 4 tests in the same day
 * Results:
 * Berg Balance Scale is best to discriminating fall risk compared to the Tinetti, EMS, and TUG
 * p<0.001
 * The component “pick up an object from floor” has highest significance to screen for potential fall risk in the elderly
 * Berg Balance Scale for discriminating between multiple fallers and non-fallers
 * Sensitivity and specificity are both 95.5% [9]

[|__https://www.youtube.com/watch?v=99I5009HFkI__]

// Timed Up and Go Test (TUG) //

TUG test is used often clinically to help therapists determine the balance, speed, and agility their patient is capable of. This test is specific for older adults. Normative test values have been established for healthy individuals. Reference values for TUG test were described in a meta-analysis by Bohannon.

The results are as follows:
 * 60-69 y.o. = 8.1 sec
 * 70-79 y.o. = 9.2 sec
 * 80-99 y.o. = 11.3 sec

21 studies were included in this meta-analysis 4395 subjects total Narrow confidence intervals for each age group

This information will give the therapist an accurate representation of the level of motor ability in their patients by comparing them to scores in healthy individuals [10].

Worse than average scores:

> > >
 * 60-69 y.o. = >9.0 sec
 * 70-79 y.o = >10.2 sec
 * 80-99 y.o. = >12.7 sec

[|__https://www.youtube.com/watch?v=j77QUMPTnE0__]

[11]
 * Body composition **
 * Tests that can be performed to test for body composition include:
 * Dual-Energy X-Ray Absorptiometry (DEXA)
 * Bioelectric impedance
 * Girth measurements
 * Body weight
 * BMI


 * Conclusion: **

A study completed by Zhao et al. aimed to identify the functional differences between elderly individuals at risk and those not at risk by comparing 7 dimensions of functional fitness

> >
 * 104 participants aged 65-74 independent with no history of falls
 * Used comprehensive tests: Fall Risk Test and Senior Fitness Test to compare 7 tests of functional fitness (BMI, 30s arm curl, chair stand, back scratch, chair sit and reach, 8 ft up and go, 2 min step test)

Results

>
 * 48 participants identified at risk, 30 not at risk

>
 * Significant difference between fall risk and no fall risk group overall functional fitness (p=0.001)

> >>
 * Significant difference between 8 feet up and go (p = <0.001), 2 minute step test (p=0.007), and 30 sec arm curl (p = 0.039)
 * Low scores correlated to increased risk of fall

Three significantly reduced dimensions that should be the focus of fall risk patients: agility and dynamic balance, aerobic endurance and muscle strength of upper limbs [12].

Our population is continually getting older and is therefore important for us personally and economically to keep the elderly physically functioning and independent as long as possible. Sedentary lifestyles have caused a decrease in physical fitness and an increased risk for health complications/falls.

Diagnostic tests have three main purposes in physical therapy: to help focus the examination in a particular body region or system, to identify potential problems that require physician referral, and to assist in the classification process [13].

Identifying physical fitness components contributing to independence and developing normative values for this population to stay independent is essential in identifying at risk patients for falls and other health complications. Physical fitness limitations directly influence function which corresponds to disability/dependence.

There are tests out there that encompass multiple areas physical fitness which we outlined (aerobic endurance, muscular strength, motor ability, flexibility, and body composition), such as the Elderly Mobility Scale, Fullerton Functional Fitness Test for Older Adults, and Senior Fitness Test. These are tools that may be good for an evaluation, and to get many objective measures but the problem is they don’t always use the best measure for each component. For example, the Senior Fitness Test tests strength using the chair stand test, while we found that the 5 time sit to stand has the best evidence for assessing muscular strength. It is important to, with evidence in mind, use your clinical judgment as to what you are looking to assess or diagnose with your particular patient.

A test does not exist that is “one size fits all”. As a therapist, you must utilize the best test for YOUR patient.

This presentation and tool is a reference you can use when you have elderly patients and may want to test their fitness or areas of their fitness in order to strengthen weaknesses and improve their quality of life. We kept this pretty broad though, so you should also keep in mind that the comorbidities and specifics of your patient will also guide the diagnostic test you may choose to use.



**References**
1. Rikli R, Jones C. Development and Validation of Criterion-Referenced Clinically Relevant Fitness Standards for Maintaining Physical Independence in Later Years. The Gerontologist. 2012;53(2):255-267. doi:10.1093/geront/gns071.

2. Jones J, Rikli R. Measuring Functional Fitness of Older Adults. The Journal on Active Aging. 2002:24-30. Available at: http://www.dsnm.univr.it/documenti/OccorrenzaIns/matdid/matdid182478.pdf. Accessed April 3, 2016.

3. Important Facts about Falls. Centers for Disease Control and Prevention 2016. Available at: http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html. Accessed April 3, 2016.

4. Bohannon R. Quantitative Testing of Muscle Strength: Issues and Practical Options for the Geriatric Population. Topics in Geriatric Rehabilitation. 2002;18(2):1-17. doi:10.1097/00013614-200212000-00003.

5. Whitney S, Wrisley D, Wrisley D et al. Clinical Measurement of Sit-to-Stand Performance in People With Balance Disorders: Validity of Data for the Five-Times-Sit-to-Stand Test. Physical Therapy. 2005;85(10):1034-1045.

6. Nedelec B, Dion K, Correa J, Desrosiers J. Upper Extremity Performance Test for the Elderly (TEMPA): Normative Data for Young Adults. Journal of Hand Therapy. 2011;24(1):31-43. doi:10.1016/j.jht.2010.09.001.

7. Rikli R, Jones C. A 6-MINUTE WALK TEST AS A MEASURE OF PHYSICAL ENDURANCE IN OLDER ADULTS. Medicine & Science in Sports & Exercise. 1998;30(Supplement):74. doi:10.1097/00005768-199805001-00421.

8. Jones C, Rikli R, Max J, Noffal G. The Reliability and Validity of a Chair Sit-and-Reach Test as a Measure of Hamstring Flexibility in Older Adults. Research Quarterly for Exercise and Sport. 1998;69(4):338-343. doi:10.1080/02701367.1998.10607708.

9. Chiu A, Au-Yeung S, Lo S. A comparison of four functional tests in discriminating fallers from non-fallers in older people. Disability & Rehabilitation. 2003;25(1):45-50. doi:10.1080/713813432.

10. Bohannon R. Reference Values for the Timed Up and Go Test. Journal of Geriatric Physical Therapy. 2006;29(2):64-68. doi:10.1519/00139143-200608000-00004.

11. Body Composition Tests. Topendsportscom. 2016. Available at: http://www.topendsports.com/testing/bodycomp.htm. Accessed April 3, 2016.

12. Zhao Y., Chung P.K. Differences in Functional Fitness Among Older Adults With and Without Risk of Falling. Asian Nursing Research. 2016; 10 (1): 51-55. [|__doi:10.1016/j.anr.2015.10.007.__]

13. Jewell D. Guide To Evidence-Based Physical Therapist Practice. Sudbury, MA: Jones & Bartlett Learning; 2011.