Differential determinants of physical daily activities in frail and nonfrail community-dwelling older adults

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Abstract

Background/Purpose

The purpose of this study was to determine whether or not daily activities determined by average daily steps are associated with age, gender, body mass index, fear of falling, and physical functions (locomotive function, balance function, and muscle power) in community-dwelling nonfrail and frail older adults.

Methods

This is a cross-sectional study conducted in community-dwelling older adults in Japan. Based on the Timed Up and Go (TUG) test, 629 elderly adults were divided into two groups: 515 were grouped to nonfrail elderly (TUG time less than 13.5 seconds, mean age 77.0±7.2 years) and 114 to frail elderly (TUG time of 13.5 seconds or more, mean age 76.1±7.5 years). Daily physical activities were determined by average daily steps measured by pedometer and four other physical function tests (10-m walk test, single-leg standing, functional reach, and five-chair stand test) were performed along with the assessment of fear of falling.

Results

Stepwise regression analysis revealed that age, gender, 10-m walk test, and single-leg standing were significant and independent determinants of the average step counts in the nonfrail elderly (R2=0.282, p<0.001), whereas fear of falling was the only significant and independent determinant of the average step counts in the frail elderly (R2=0.119, p<0.001).

Conclusion

These results indicate that differential factors may be related to daily activities depending on the level of frailty in community-dwelling older adults.

Keywords:

Fear of falling, Frail adults, Physical function, physical activity

Article Outline

  1. Introduction
  2. Methods
  3. Results
  4. Discussion
  5. References

Abstract

Background/Purpose

The purpose of this study was to determine whether or not daily activities determined by average daily steps are associated with age, gender, body mass index, fear of falling, and physical functions (locomotive function, balance function, and muscle power) in community-dwelling nonfrail and frail older adults.

Methods

This is a cross-sectional study conducted in community-dwelling older adults in Japan. Based on the Timed Up and Go (TUG) test, 629 elderly adults were divided into two groups: 515 were grouped to nonfrail elderly (TUG time less than 13.5 seconds, mean age 77.0±7.2 years) and 114 to frail elderly (TUG time of 13.5 seconds or more, mean age 76.1±7.5 years). Daily physical activities were determined by average daily steps measured by pedometer and four other physical function tests (10-m walk test, single-leg standing, functional reach, and five-chair stand test) were performed along with the assessment of fear of falling.

Results

Stepwise regression analysis revealed that age, gender, 10-m walk test, and single-leg standing were significant and independent determinants of the average step counts in the nonfrail elderly (R2=0.282, p<0.001), whereas fear of falling was the only significant and independent determinant of the average step counts in the frail elderly (R2=0.119, p<0.001).

Conclusion

These results indicate that differential factors may be related to daily activities depending on the level of frailty in community-dwelling older adults.

Keywords:

Fear of falling, Frail adults, Physical function, physical activity

1. Introduction

Physical activities show positive associations with various components of physical functions, such as walking speed, lower-limb strength, and balance and negative associations with the incidence of coronary artery disease, obesity, osteoporosis, and other causes of morbidity and mortality in elderly.1,2,3,4

Higher physical activities can also improve quality of life and physical and psychological functions, facilitate independent living, and reduce the risk of dementia in older adults.5,6,7,8 Physical Activity Guidelines for Americans concluded that, for older adults, in addition to the well-known health benefits of a physically active lifestyle, “strong evidence indicates that being physically active is associated with higher levels of functional health and a lower risk of falling.”9

However, Yoshida et al10 showed that the association between physical fitness and ambulatory activity is affected by the level of instrumental activity of daily life in elderly women, suggesting the effect of frailty on the association. We demonstrated that the resistance training program is effective at decreasing the fear of falling in frail elderly but not in nonfrail elderly (Yamada et al, present study), indicating the difference of the effect of physical training in elderly with different physical fitness. We hypothesized, therefore, that differential factors could affect the level of physical daily activities in the presence or absence of frailty. The purpose of this study was to determine whether or not physical activities determined by average daily steps are associated with age, gender, body mass index (BMI), fear of falling, and physical function (locomotive function, balance function, and muscle power) in community-dwelling nonfrail and frail older adults.

2. Methods

2.1. Participants

Participants were recruited by an advertisement in a local press. We used the following criteria to screen participants in the initial interview and invited to participate in this study if he or she was aged 65 years or older, was community-dwelling, had a score of eight or more by Rapid Dementia Screening Test,11 and was able to walk independently.

We excluded participants based on the following exclusion criteria: the presence of severe cardiac, pulmonary, or musculoskeletal disorders; comorbidities associated with an increased risk of falls (i.e., Parkinson’s disease or stroke); and use of psychotropic drugs. We obtained written informed consent from each participant in accordance with the guidelines approved by the Kyoto University Graduate School of Medicine and the Declaration of Human Rights, Helsinki, 1975.

2.2. Definition of frailty

The definition of frailty is based on the results of previous study. The Timed Up and Go (TUG) is a simple test developed to screen basic mobility performance and has been shown to be significantly associated with activities of daily living function in frail older adults.12 It has been reported that elderly with a TUG score greater than 13.5 seconds have an increased risk of falls.13 Therefore, frailty was defined as a TUG score greater than 13.5 seconds. Based on key components of the screening examination (TUG score greater than 13.5 seconds), 114 elderly were classified as frail, whereas 515 elderly as nonfrail.

2.3. Measurement of physical activities

A valid, accurate, and reliable pedometer, Yamax PowerWalker EX-510 (Yamax Corp., Tokyo, Japan), was used to measure free-living step counts.14 Measurement of step counts was conducted between October and November 2010. Participants were instructed to wear the pedometer in their pocket of dominant leg for 14 consecutive days except during bathing, sleeping, and performing water-based activities. This pedometer has a 30-day data storage capacity. We calculated the averages of their daily step counts for 2 weeks.

2.4. Measurement of fear of falling

We assessed fear of falling by asking a single yes or no question, “Are you afraid of falling,?” which has a high test-retest reliability.15 The test-retest reliability using the Kappa coefficient was 0.960.

2.5. Measurement of physical function

The participants received four other physical function tests that are widely used to identify high-risk elderly: 10-m walk test, single-leg standing, functional reach, and five-chair stand. In 10-m walk test, the participants were asked to walk as fast as possible along a 10-m straight line, with a 1 m approach at both ends, making a total length of 12 m. The time required was taken as the measured value. In single-leg standing, the length of time for which participants were able to stand on one leg with their hands placed on their waist was measured. The time was measured twice for each leg and the maximum length of time was taken. Functional reach was measured using the simple clinical apparatus consisting of a leveled yardstick secured to the wall at right acromion height as previously described.16 In five-chair stand, participants were asked to stand up and sit down five times as quickly as possible and were timed from the initial sitting position to the final standing position at the end of the fifth stand.17 For each function test, the participants performed twice, and the average score was then calculated. All test measurements were completed before the daily step measurement.

2.6. Statistical analysis

The relationship between the average daily steps and physical function was investigated with the Pearson correlation coefficient. The t test and χ2 test were used to compare the results of measurements between frail and nonfrail groups.

A multivariate analysis by means of multiple regression using a stepwise method was performed to investigate which of the age, gender, BMI, fear of falling, and five measures of physical function (i.e., 10-m walk test, TUG, single-leg standing, functional reach, and five-chair stand test) were independently associated with the average daily steps in each group.

Data were analyzed using the Statistical Package for Social Science (Windows version 18.0; SPSS Inc., Chicago, IL, USA).

3. Results

There were no significant differences in age (nonfrail=77.0±7.2, frail=76.1±7.5, p=0.241), gender (nonfrail=67.5%, frail=67.5%, p=0.541), height (nonfrail=153.5±7.6 cm, frail=153.7±6.1 cm, p=0.743), weight (nonfrail=53.0±9.6 kg, frail=53.6±4.5 kg, p=0.576), and BMI (nonfrail=22.4±3.2, frail=22.7±1.9, p=0.393) between the two groups (Table 1). However, all physical function tests and average daily steps were significantly different between the two groups. More fear of falling was observed (nonfrail=39.1%, frail=73.6%, p<0.001), longer time was required for 10-m walk test (nonfrail=9.9±2.2 seconds, frail=17.1±6.6 seconds, p<0.001), single-leg standing (nonfrail=13.3±12.1 seconds, frail=3.1±6.0 seconds, p<0.001), and five-chair stand (nonfrail=8.9±3.6 seconds, frail=17.6±8.5 seconds, p<0.001) in frail elderly. Less functional reach (nonfrail=25.0±8.2 cm, frail=17.9±8.4 cm, p<0.001), and average daily steps (nonfrail=4414±2726 steps, frail=1585±1013 steps, p<0.001) were observed in frail elderly.

Table 1Comparison of demography, fear of falling, and physical function and activities between nonfrail and frail elderly
Items Nonfrail group (n=515) Frail group (n=114) p
Mean SD Mean SD
Age (yr) 77.0 7.2 76.1 7.5 0.241
Gender (male=0, female=1) 67.5 67.5 0.541a
Height 153.5 7.6 153.7 6.1 0.743
Weight 53.0 9.6 53.6 4.5 0.576
BMI (kg/m2) 22.4 3.2 22.7 1.9 0.393
Fear of falling (yes=1, no=0) 39.1 73.6 <0.001a
10-m walking time (s) 9.9 2.2 17.1 6.6 <0.001
Timed up & go test (s) 8.8 2.1 20.2 6.8 <0.001
Single leg standing (s) 13.3 12.1 3.1 6.0 <0.001
Functional reach (cm) 25.0 8.2 17.9 8.4 <0.001
Five chair stand (s) 8.9 3.6 17.6 8.5 <0.001
Average daily step (step) 4414.4 2726.3 1585.0 1012.6 <0.001

BMI=body mass index; SD=standard deviation.

aχ2 test.

To determine the association of average step counts with physical functions and demography, we analyzed Pearson’s correlation coefficients in frail and nonfrail elderly. Table 2 shows that average step counts in the nonfrail group were correlated with age (r=−0.311, p<0.001), BMI (r=0.167, p<0.001), 10-m walk test (r=−0.475, p<0.001), TUG (r=−0.412, p<0.001), functional reach (r=0.348, p<0.001), five chair stand test (r=−0.297, p<0.001), and single-leg standing test (r=0.440, p<0.001). In the frail group, however, a significant association was found only with five-chair stand test (r=−0.226, p<0.001). Figure 1 shows linear regressions between physical functions and average step counts in nonfrail and frail elderly. Average step counts had a positive association with functional reach (Fig. 1C) and negative associations with 10-m walk test (Fig. 1A) and TUG (Fig. 1B) only in nonfrail elderly. However, step counts had a negative association with five-chair stand (Fig. 1D) both in nonfrail and frail elderly.

Table 2Pearson’s correlation coefficients (r) between average daily steps and physical functions, age, and BMI
Items Nonfrail group (n=515) Frail group (n=114) Overall (n=629)
Age (yr) −0.311** −0.109 −0.241**
BMI (kg/m2) 0.167** −0.013 0.130**
10-m walking time (s) −0.475** −0.047 −0.448**
Timed up & go test (s) −0.412** −0.131 −0.450**
Functional reach (cm) 0.348** 0.175 0.406**
Five-chair stand (s) −0.297** −0.226* −0.397**
Single-leg standing (s) 0.440** 0.077 0.502**

BMI=body mass index.

*p<0.05; **p<0.01.

Fig. 1

Relationships between average daily steps and physical function. The physical function was associated with physical activities in nonfrail but not in frail elderly. (A) 10-m walk test; (B) Timed up and go test; (C) Functional reach; (D) Five-chair stand test.

Stepwise regression analysis revealed that age (β=−0.108, p=0.03), gender (β=0.255, p<0.001), 10-m walk test (β=−0.202, p<0.001) and single-leg standing (β=0.306, p<0.001) were significant and independent determinants of the average step counts in nonfrail elderly (R2=0.282, p<0.001) (Table 3). Stepwise regression analysis also revealed that fear of falling (β=−0.356, p<0.001) was the only significant and independent determinant of the average step counts in frail elderly (R2=0.119, p<0.001) (Table 3).

Table 3Multiple stepwise regression analysis
Independent variables Nonfrail group Adjusted R2 value=0.282 standard regression value Frail group Adjusted R2 value=0.119 standard regression value Overall Adjusted R2 value=0.345 standard regression value
Age (yr) −0.108* −0.137**
BMI (kg/m2)
Gender (male=0, female=1) 0.255** 0.238**
Fear of falling (yes=1, no=0) −0.356** −0.089*
10-m walking time (s) −0.202** −0.172**
Timed up & go test (s)
Functional reach (cm)
Five chair stand (s) −0.147**
Single leg standing (s) 0.306** 0.314**

*p<0.05; **p<0.01.

4. Discussion

In the present study, we showed that the differential factors of physical functions may relate to the daily activities in frail and nonfrail community-dwelling elderly Japanese. Our data implicate that physical daily activities can be maintained in the robust elderly with high physical function, whereas fear of falling plays a more important role for the maintenance of physical daily activities if an older adult becomes functionally impaired and frail. Previous studies also indicated that the low self-efficacy for daily activities reduces physical activity, and psychological well-being is an important predictor for staying physically active.18,19 Thus, differential approaches should be taken to keep the daily activities depending on their physical fitness in elderly.

The physical functions, age, and gender were associated with daily activities in nonfrail elderly but not in frail elderly. Rantanen et al20 also reported that the relationship between muscle strength and physical disability in older adults is nonlinear. Moreover, in most of previous reports, the participants were nonfrail older adults.1,2,3,4 Therefore, it has been assumed that there is an association between daily activities and physical functions. In addition, daily activities tended to be greater in women than in men. The reason for greater daily activities in women is often ascribed to activities, such as housework and gardening.20

On the other hand, we demonstrated that fear of falling was associated with physical daily activities in frail elderly but not in nonfrail elderly. Fear of falling is shown to be associated with frailty.21,22 Several studies have indicated that people who are afraid of falling appear to enter a debilitating spiral of loss of confidence, restriction of physical activities, physical frailty, lack of social participation, falls, and loss of independence.23,24,25,26,27,28 However, Wolf et al29 reported that increased core and lower extremity strength with exercise decreases the fear of falling. Moreover, cognitive behavioral therapy has been shown to reduce fear of falling.30,31,32

There were several limitations of this study that warrant mention. First, although we used TUG to define frailty, TUG may not be enough to define frailty. Edmonton frail scale adopts eight other domains, such as cognition, general health status, functional independence, social support, medication use, nutrition, mood, and continence other than TUG.33Further study is required to test the levels of these domains in this cohort. Second, participants have used pedometer measurements limited to only 2 weeks. If seasonal changes in activity pattern were taken into consideration, long-term use would be more appropriate. Third, the participant’s community was not in the rural area. The present study is the result of being restricted to older adults in the urban area.

This is the first study to demonstrate that differential factors affect daily activities depending on the level of frailty. Future work should determine whether individualized intervention can effectively improve physical activity in both nonfrail and frail elderly.

Acknowledgments

We would like to thank Nippon-Shooter Co. Ltd. for their contribution to data collection and Mr Minoru Ikeda and Mr Yusuke Terasaki for their helpful advice.

References

  1. Aoyagi, Y. and Katsuta, S. Relationship between the starting age of training and physical fitness in old age. Can J Sport Sci. 1990; 15: 65–71
  2. Aoyagi, Y. and Shephard, R.J. Aging and muscle function. Sports Med. 1992; 14: 376–396
  3. Aoyagi, Y. and Shephard, R.J. Steps per day: the road to senior health?. Sports Med. 2009; 39: 423–438
  4. Nelson, M.E., Rejeski, W.J., Blair, S.N., Duncan, P.W., Judge, J.O., King, A.C. et al. Physical activity and public health in older adults: recommendation from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc. 2007; 39: 1435–1445
  5. Singh, N.A., Clements, K.M., and Singh, M.A. The efficacy of exercise as a long-term antidepressant in elderly subjects: a randomized controlled trial. J Gerontol A Biol Sci Med Sci. 2001; 56: M497–M504
  6. Mazzeo, R.S., Cavanagh, P., Evans, W.J., Fiatarone, M., Hagberg, J., McAuley, E. et al. American College of Sports Medicine Position Stand. Exercise and physical activity for older adults. Med Sci Sports Exerc. 1998; 30: 992–1008
  7. Simons, L.A., Simons, J., McCallum, J., and Friedlander, Y. Lifestyle factors and risk of dementia: Dubbo study of the elderly. Med J Aust. 2006; 184: 68–70
  8. Spirduso, W.W. and Cronin, D.L. Exercise dose-response effects on quality of life and independent living in older adults. Med Sci Sports Exerc. 2001; 33: S598–S608
  9. Physical Activity Guidelines Advisory Committee. Physical Activity Guidelines Advisory Committee Report, 2008. U.S. Department of Health and Human Services, Washington, D.C.; 2008
  10. Yoshida, D., Nakagaichi, M., Saito, K., Wakui, S., and Yoshitake, Y. The relationship between physical fitness and ambulatory activity in very elderly women with normal functioning and functional limitation. J Physiol Anthropol. 2010; 29: 211–218
  11. Kalbe, E., Calabrese, P., Scgwalen, S., and Kessler, J. The Rapid Dementia Screening Test (RDST): a new economical tool for detecting possible patients with dementia. Dement Geriatr Cogn Disord. 2003; 16: 193–199
  12. Podsiadlo, D. and Richardson, S. The timed “Up & Go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991; 39: 142–148
  13. Shumway-Cook, A., Brauer, S., and Woollacott, M. Predicting the probability for falls in community-dwelling older adults using the Timed Up & Go Test. Phys Ther. 2000; 80: 896–903
  14. Crouter, S.E., Schneider, P.L., Karabulut, M., and Bassett, D.R. Jr. Validity of 10 electronic pedometers for measuring steps, distance, and energy cost. Med Sci Sports Exerc. 2003; 35: 1455–1460
  15. Reelick, M.F., van Iersel, M.B., Kessels, R.P., and Rikkert, M.G. The influence of fear of falling on gait and balance in older people. Age Ageing. 2009; 38: 435–440
  16. Duncan, P.W., Weiner, D.K., Chandler, J., and Prescott, B. Functional reach: a new clinical measure of balance. J Gerontol. 1990; 45: M192–M197
  17. Guralnik, J.M., Simonsick, E.M., Ferrucci, L., Glynn, R.J., Berkman, L.F., Blazer, D.G. et al. A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission. J Gerontol. 1994; 49: M85–M94
  18. Ruuskanen, J.M. and Ruoppila, I. Physical activity and psychological well-being among people aged 65-84 years. Age Ageing. 1995; 24: 292–296
  19. Kono, A., Kai, I., Sakato, C., and Rubenstein, L.Z. Frequency of going outdoors: a predictor of functional and psychosocial change among ambulatory frail elders living at home. J Gerontol A Biol Sci Med Sci. 2004; 59: 275–280
  20. Rantanen, T., Guralnik, J.M., Ferrucci, L., Penninx, B.W., Leveille, S., Sipila, S. et al. Coimpairments as predictors of severe walking disability in older women. J Am Geriatr Soc. 2001; 49: 21–27
  21. Cumming, R.G., Salkeld, G., Thomas, M., and Szonyi, G. Prospective study of the impact of fear of falling on activities of daily living, SF-36 scores, and nursing home admission. J Gerontol A Biol Sci Med Sci. 2000; 55: 299–305
  22. Delbaere, K., Crombez, G., Vanderstraeten, G., Willems, T., and Cambier, D. Fear-related avoidance of activities, falls and physical frailty. A prospective community-based cohort study. Age Ageing. 2004; 33: 368–373
  23. Friedman, S.M., Munoz, B., West, S.K., Rubin, G.S., and Fried, L.P. Falls and fear of falling: which comes first? A longitudinal prediction model suggests strategies for primary and secondary prevention. J Am Geriatr Soc. 2002; 50: 1329–1335
  24. Lachman, M.E., Howland, J., Tennstedt, S., Jette, A., Assman, S., and Peterson, E.W. Fear of falling and activity restriction: the survey of activities and fear of falling in the elderly (SAFE). J Gerontol B Psychol Sci Soc Sci. 1998; 53: P43–P50
  25. Arfken, C.L., Lach, H.W., Birge, S.J., and Miller, J.P. The prevalence and correlates of fear of falling in elderly persons living in the community. Am J Public Health. 1994; 84: 565–570
  26. Howland, J., Peterson, E.W., Levin, W.C., Fried, L., Pordon, D., and Bak, S. Fear of falling among the community-dwelling elderly. J Aging Health. 1993; 5: 229–243
  27. Cumming, R.G., Salkeld, G., Thomas, M., and Szonyi, G. Prospective study of the impact of fear of falling on activities of daily living, SF-36 scores, and nursing home admission. J Gerontol A Biol Sci Med Sci. 2000; 55: M299–M305
  28. Delbaere, K., Crombez, G., Vanderstraeten, G., Willems, T., and Cambier, D. Fear-related avoidance of activities, falls and physical frailty. A prospective community-based cohort study. Age Ageing. 2004; 33: 368–373
  29. Wolf, S., Barnhart, H., Kutner, N., McNeely, E., Coogler, C., Xu, T. et al. Selected as the best paper in the 1990s: reducing frailty and falls in older persons: an investigation of tai chi and computerized balance training. J Am Geriatar Soc. 2003; 51: 1794–1803
  30. Brouwer, B.J., Walker, C., Rydahl, S.J., and Culham, E.G. Reducing fear of falling in seniors through education and activity programs: a randomized trial. J Am Geriatr Soc. 2003; 51: 829–834
  31. Tennstedt, S., Howland, J., Lachman, M., Peterson, E., Kasten, L., and Jette, A. A randomized, controlled trial of a group intervention to reduce fear of falling and associated activity restriction in older adults. J Gerontol B Psychol Sci Soc Sci. 1998; 53: 384–392
  32. Zijlstra, G.A.R., Van Haastregt, J.C.M., Ambergen, T., Van Rossum, E., Van Eijk, J.T.M., Tennstedt, S.L. et al. Effects of a multicomponent cognitive behavioral group intervention on fear of falling and activity avoidance in community-dwelling older adults: results of a randomized controlled trial. J Am Geriatr Soc. 2009; 57: 2020–2028
  33. Rolfson, D.B., Majumdar, S., Tsuyuki, R.T., Tahir, A., and Rockwood, K. Validity and reliability of the Edmonton Frail Scale. Age Ageing. 2006; 35: 526–529

Fig. 1

Relationships between average daily steps and physical function. The physical function was associated with physical activities in nonfrail but not in frail elderly. (A) 10-m walk test; (B) Timed up and go test; (C) Functional reach; (D) Five-chair stand test.

References

  1. Aoyagi, Y. and Katsuta, S. Relationship between the starting age of training and physical fitness in old age. Can J Sport Sci. 1990; 15: 65–71

  2. Aoyagi, Y. and Shephard, R.J. Aging and muscle function. Sports Med. 1992; 14: 376–396


  3. Aoyagi, Y. and Shephard, R.J. Steps per day: the road to senior health?. Sports Med. 2009; 39: 423–438


  4. Nelson, M.E., Rejeski, W.J., Blair, S.N., Duncan, P.W., Judge, J.O., King, A.C. et al. Physical activity and public health in older adults: recommendation from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc. 2007; 39: 1435–1445


  5. Singh, N.A., Clements, K.M., and Singh, M.A. The efficacy of exercise as a long-term antidepressant in elderly subjects: a randomized controlled trial. J Gerontol A Biol Sci Med Sci. 2001; 56: M497–M504


  6. Mazzeo, R.S., Cavanagh, P., Evans, W.J., Fiatarone, M., Hagberg, J., McAuley, E. et al. American College of Sports Medicine Position Stand. Exercise and physical activity for older adults. Med Sci Sports Exerc. 1998; 30: 992–1008


  7. Simons, L.A., Simons, J., McCallum, J., and Friedlander, Y. Lifestyle factors and risk of dementia: Dubbo study of the elderly. Med J Aust. 2006; 184: 68–70


  8. Spirduso, W.W. and Cronin, D.L. Exercise dose-response effects on quality of life and independent living in older adults. Med Sci Sports Exerc. 2001; 33: S598–S608


  9. Physical Activity Guidelines Advisory Committee. Physical Activity Guidelines Advisory Committee Report, 2008. U.S. Department of Health and Human Services, Washington, D.C.; 2008


  10. Yoshida, D., Nakagaichi, M., Saito, K., Wakui, S., and Yoshitake, Y. The relationship between physical fitness and ambulatory activity in very elderly women with normal functioning and functional limitation. J Physiol Anthropol. 2010; 29: 211–218


  11. Kalbe, E., Calabrese, P., Scgwalen, S., and Kessler, J. The Rapid Dementia Screening Test (RDST): a new economical tool for detecting possible patients with dementia. Dement Geriatr Cogn Disord. 2003; 16: 193–199


  12. Podsiadlo, D. and Richardson, S. The timed “Up & Go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991; 39: 142–148


  13. Shumway-Cook, A., Brauer, S., and Woollacott, M. Predicting the probability for falls in community-dwelling older adults using the Timed Up & Go Test. Phys Ther. 2000; 80: 896–903


  14. Crouter, S.E., Schneider, P.L., Karabulut, M., and Bassett, D.R. Jr. Validity of 10 electronic pedometers for measuring steps, distance, and energy cost. Med Sci Sports Exerc. 2003; 35: 1455–1460


  15. Reelick, M.F., van Iersel, M.B., Kessels, R.P., and Rikkert, M.G. The influence of fear of falling on gait and balance in older people. Age Ageing. 2009; 38: 435–440


  16. Duncan, P.W., Weiner, D.K., Chandler, J., and Prescott, B. Functional reach: a new clinical measure of balance. J Gerontol. 1990; 45: M192–M197


  17. Guralnik, J.M., Simonsick, E.M., Ferrucci, L., Glynn, R.J., Berkman, L.F., Blazer, D.G. et al. A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission. J Gerontol. 1994; 49: M85–M94


  18. Ruuskanen, J.M. and Ruoppila, I. Physical activity and psychological well-being among people aged 65-84 years. Age Ageing. 1995; 24: 292–296


  19. Kono, A., Kai, I., Sakato, C., and Rubenstein, L.Z. Frequency of going outdoors: a predictor of functional and psychosocial change among ambulatory frail elders living at home. J Gerontol A Biol Sci Med Sci. 2004; 59: 275–280


  20. Rantanen, T., Guralnik, J.M., Ferrucci, L., Penninx, B.W., Leveille, S., Sipila, S. et al. Coimpairments as predictors of severe walking disability in older women. J Am Geriatr Soc. 2001; 49: 21–27


  21. Cumming, R.G., Salkeld, G., Thomas, M., and Szonyi, G. Prospective study of the impact of fear of falling on activities of daily living, SF-36 scores, and nursing home admission. J Gerontol A Biol Sci Med Sci. 2000; 55: 299–305


  22. Delbaere, K., Crombez, G., Vanderstraeten, G., Willems, T., and Cambier, D. Fear-related avoidance of activities, falls and physical frailty. A prospective community-based cohort study. Age Ageing. 2004; 33: 368–373


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