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1.  Lipopolysaccharide-Binding Protein, a Surrogate Marker of Microbial Translocation, Is Associated With Physical Function in Healthy Older Adults 
Physical function declines, and markers of inflammation increase with advancing age, even in healthy persons. Microbial translocation (MT) is the systemic exposure to mucosal surface microbes/microbial products without overt bacteremia and has been described in a number of pathologic conditions. We hypothesized that markers of MT, soluble CD14 (sCD14) and lipopolysaccharide (LPS) binding protein (LBP), may be a source of chronic inflammation in older persons and be associated with poorer physical function.
We assessed cross-sectional relationships among two plasma biomarkers of MT (sCD14 and LBP), physical function (hand grip strength, short physical performance battery [SPPB], gait speed, walking distance, and disability questionnaire), and biomarkers of inflammation (C-reactive protein (CRP), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), TNF-α soluble receptor 1 [TNFsR1]) in 59 older (60–89 years), healthy (no evidence of acute or chronic illness) men and women.
LBP was inversely correlated with SPPB score and grip strength (p = .02 and p < .01, respectively) and positively correlated with CRP (p = 0.04) after adjusting for age, gender, and body mass index. sCD14 correlated with IL-6 (p = .01), TNF-α (p = .05), and TNFsR1 (p < .0001). Furthermore, the correlations between LBP and SPPB and grip strength remained significant after adjusting for each inflammatory biomarker.
In healthy older individuals, LBP, a surrogate marker of MT, is associated with worse physical function and inflammation. Additional study is needed to determine whether MT is a marker for or a cause of inflammation and the associated functional impairments.
PMCID: PMC3636679  PMID: 22960476
Microbial translocation; Inflammation; Physical function; Microbiome
2.  Comparing Pain Severity Versus Pain Location in the MOBILIZE Boston Study: Chronic Pain and Lower Extremity Function* 
This study compared measures of chronic pain, for example, number of pain sites and overall pain severity, in relation to lower extremity function in the older population.
Six hundred older adults (mean age 77.9 years, 64% female) were queried about presence of chronic pain. Number of pain sites was categorized as none, single site, multisite, or widespread. Pain severity was measured in quartiles of the Brief Pain Inventory pain severity subscale. Lower extremity function was assessed by the Short Physical Performance Battery (SPPB), a composite measure of gait speed, balance, and chair stands.
Many older persons reported multisite or widespread pain (40%). Increased pain sites and pain severity were associated with poorer SPPB performance after adjusting for age, sex, height, and weight. With further adjustment for education, comorbid conditions, and depressive symptoms, multisite pain (p < .001) and most severe pain (p < .05) were associated with poorer SPPB performance, but assessed together in the same model, only the association with multisite/widespread pain remained significant (p < .01). When specific joint pain sites were evaluated together, only knee pain was associated with lower SPPB score. Pain severity was independently associated with slower gait, pain location was associated with poorer balance, and chair stands performance was associated with both pain measures.
Although multisite pain rather than pain severity was more strongly associated with overall lower extremity function, differences emerged with specific SPPB subtests. Longitudinal studies are needed to understand risk for lower extremity function decline related to chronic pain characteristics in older adults.
PMCID: PMC2691797  PMID: 19228782
Pain; Mobility; Aging; Lower extremity function; Epidemiology
3.  Relationship Between Poor Physical Function, Inflammatory Markers, and Comorbidities in HIV-Infected Women on Antiretroviral Therapy 
Journal of Women's Health  2014;23(1):69-76.
Background: HIV-infected individuals may be at increased risk of poor physical function. Chronic inflammation has been associated with decreased physical function in the elderly and may also influence physical function in HIV-infected individuals.
Methods: This cross-sectional study assessed physical function in 65 HIV-infected women aged 40 and older on stable antiretroviral treatment using the Short Physical Performance Battery (SPPB): a standardized test of balance, walking speed, and lower- extremity strength developed for elderly populations. The relationship between low SPPB score, selected demographic and medical characteristics, and high inflammatory biomarker profile was analyzed using Fisher's exact test and Wilcoxon rank sum test.
Results: The median age of subjects was 49 years (interquartile range [IQR] 45–55), and the median CD4 T-cell count was 675 cells/mm3 (IQR 436–828). Thirteen subjects (20%) had a low SPPB score. Subjects with a low SPPB score were more likely to be cigarette smokers (p=0.03), had more medical comorbidities (p=0.01), and had higher levels of interleukin-6 (IL-6) (p<0.05). They also tended to be older (median age 55 vs. 48, p=0.06), more likely to have diabetes (p=0.07), and have higher levels of soluble tumor necrosis factor-1 (p=0.09).
Conclusions: Twenty percent of women aged 40 and older with well-treated HIV had poor physical-function performance, which was associated with the high burden of comorbidities in this population and with increased IL-6. However, it is unclear from this cross-sectional study whether increased inflammation was related to poor physical function or to other factors, such as age and medical comorbidities.
PMCID: PMC3880911  PMID: 24219874
4.  Relationship Between Renal Function and Physical Performance in Elderly Hospitalized Patients 
Rejuvenation Research  2012;15(6):545-552.
Chronic kidney disease (CKD) is increasingly recognized as a cause of worsening physical functioning in older patients. The Short Physical Performance Battery (SPPB) is highly reliable in older populations, but no data on older hospitalized patients with different degrees of kidney function are available. We aimed at testing the association between estimated glomerular filtration rate (eGFR) and SPPB, either global score (range 0–12) or its individual components (muscle strength, balance, and walking speed, each ranging from 0 to 4), in a sample of older hospitalized patients. Our series consisted of 486 patients aged 65 or more consecutively enrolled in 11 acute care medical wards participating to a multicenter observational study. eGFR was obtained by the Chronic Kidney Disease Epidemiological Collaboration (CKD-EPI) equation. Physical performance was objectively measured by the SPPB. The relationship between eGFR and SPPB was investigated by multiple linear regression analysis. Physically impaired patients (SPPB total score<5) were older, had lower serum albumin and Mini-Mental State Examination (MMSE) scores as well as higher overall co-morbidity, prevalence of stroke, cancer, and anemia compared to those with intermediate (SPPB=5–8) and good physical performance (SPPB=9–12). Fully adjusted multivariate models showed that eGFR (modeled as 10 mL/min per 1.73 m2 intervals) was independently associated with the SPPB total score (B=0.49; 95% confidence interval [CI]=0.18–0.66; p=0.003), balance (B=0.30; 95% CI=0.10–0.49; p=0.005), and muscle strength (B=0.06; 95% CI=0.01–0.10; p=0.043), but not with walking speed (B=−0.04; 95% CI=−0.09–0.11; p=0.107). In conclusion, reduced renal function is associated with poorer physical performance in older hospitalized patients. SPPB is worthy of testing to monitor changes in physical performance in elderly CKD patients.
PMCID: PMC3549205  PMID: 22950422
5.  Validity and reliability of the Short Physical Performance Battery (SPPB) 
Colombia Médica : CM  null;44(3):165-171.
To assess the validity (convergent and construct) and reliability of the Short Physical Performance Battery (SPPB) among non-disabled adults between 65 to 74 years of age residing in the Andes Mountains of Colombia.
Design Validation study; Participants:
150 subjects aged 65 to 74 years recruited from elderly associations (day-centers) in Manizales, Colombia. Measurements: The SPPB tests of balance, including time to walk 4 meters and time required to stand from a chair 5 times were administered to all participants. Reliability was analyzed with a 7-day interval between assessments and use of repeated ANOVA testing. Construct validity was assessed using factor analysis and by testing the relationship between SPPB and depressive symptoms, cognitive function, and self rated health (SRH), while the concurrent validity was measured through relationships with mobility limitations and disability in Activities of Daily Living (ADL). ANOVA tests were used to establish these associations.
Test-retest reliability of the SPPB was high: 0.87 (CI95%: 0.77-0.96). A one factor solution was found with three SPPB tests. SPPB was related to self-rated health, limitations in walking and climbing steps and to indicators of disability, as well as to cognitive function and depression. There was a graded decrease in the mean SPPB score with increasing disability and poor health.
The Spanish version of SPPB is reliable and valid to assess physical performance among older adults from our region. Future studies should establish their clinical applications and explore usage in population studies.
PMCID: PMC4002038  PMID: 24892614
SPPB; aging; reliability; validity; validation studies; disability; Colombia
6.  Physical function and self-rated health status as predictors of mortality: results from longitudinal analysis in the ilSIRENTE study 
BMC Geriatrics  2008;8:34.
Physical function measures have been shown to predict negative health-related events in older persons, including mortality. These markers of functioning may interact with the self-rated health (SRH) in the prediction of events. Aim of the present study is to compare the predictive value for mortality of measures of physical function and SRH status, and test their possible interactions.
Data are from 335 older persons aged ≥ 80 years (mean age 85.6 years) enrolled in the "Invecchiamento e Longevità nel Sirente" (ilSIRENTE) study. The predictive values for mortality of 4-meter walk test, Short Physical Performance Battery (SPPB), hand grip strength, Activities of Daily Living (ADL) scale, Instrumental ADL (IADL) scale, and a SRH scale were compared using proportional hazard models. Kaplan-Meier survival curves for mortality and Receiver Operating Characteristic (ROC) curve analyses were also computed to estimate the predictive value of the independent variables of interest for mortality (alone and in combination).
During the 24-month follow-up (mean 1.8 years), 71 (21.2%) events occurred in the study sample. All the tested variables were able to significantly predict mortality. No significant interaction was reported between physical function measures and SRH. The SPPB score was the strongest predictor of overall mortality after adjustment for potential confounders (per SD increase; HR 0.64; 95%CI 0.48–0.86). A similar predictive value was showed by the SRH (per SD increase; HR 0.76; 95%CI 0.59–0.97). The chair stand test was the SPPB subtask showing the highest prognostic value.
All the tested measures are able to predict mortality with different extents, but strongest results were obtained from the SPPB and the SRH. The chair stand test may be as useful as the complete SPPB in estimating the mortality risk.
PMCID: PMC2628909  PMID: 19102751
7.  Increased inflammation but similar physical composition and function in older-aged, HIV-1 infected subjects 
BMC Immunology  2015;16:43.
Systemic immune activation (inflammation) and immunosenescence develop in some people with advancing age. This process, known as “inflamm-aging,” is associated with physical frailty and sarcopenia. Meanwhile, successful antiretroviral therapy has led to a growing number of older HIV-1-infected individuals who face both age-related and HIV-1-related inflammation, which may synergistically promote physical decline, including frailty and sarcopenia. The purpose of our study was to determine if inflammation during treated HIV-1 infection worsens physical impairment in older individuals.
We determined the severity of HIV-associated inflammation and physical performance (strength and endurance) in 21 older HIV-infected individuals (54–69 years) receiving suppressive antiretroviral therapy, balanced for confounding variables including age, anthropometrics, and co-morbidities with 10 uninfected control individuals. Biomarkers for microbial translocation (lipopolysaccharide [LPS]), inflammation (soluble CD14 [sCD14], osteopontin, C-reactive protein [CRP], interleukin-6 [IL-6], soluble ICAM-1 [sICAM-1] and soluble VCAM-1 [sVCAM-1]), and coagulopathy (D-dimer) were assayed in plasma. Activation phenotypes of CD4+T cells, CD8+ T cells and monocytes were measured by flow cytometry. Physical performance was measured by 400 m walking speed, a short physical performance battery [SPPB], and lower extremity muscle strength and fatigue.
Overall physical function was similar in the uninfected and HIV-infected groups. Compared to uninfected individuals, the HIV-infected group had elevated levels of sCD14 (P < 0.001), CRP (P < 0.001) and IL-6 (P = 0.003) and an increased frequency of CD4+ and CD8+ T cells with an immunosenescent CD57+ phenotype (P = 0.004 and P = 0.043, respectively). Neither plasma inflammatory biomarkers nor CD57+ T cells correlated with CD4+ T cell counts. Furthermore, none of the elevated inflammatory biomarkers in the HIV-infected subjects were associated with any of the physical performance results.
When age-related co-morbidities were carefully balanced between the uninfected and HIV-infected groups, no evidence of inflammation-associated physical impairment was detected. Despite careful balancing for age, BMI, medications and co-morbidities, the HIV-infected group still displayed evidence of significant chronic inflammation, including elevated sCD14, CRP, IL-6 and CD57+ T cells, although the magnitude of this inflammation was unrelated to physical impairment.
PMCID: PMC4513956  PMID: 26204934
8.  Association Between Inflammatory Components and Physical Function in the Health, Aging, and Body Composition Study: A Principal Component Analysis Approach 
In older adults, studies demonstrate an inverse relationship between physical function and individual inflammatory biomarkers. Given that the inflammatory response is a complex system, a combination of biomarkers may increase the strength and consistency of these associations. This study uses principal component analysis to identify inflammatory “component(s)” and evaluates associations between the identified component(s) and measures of physical function.
Principal component analysis with a varimax rotation was used to identify two components from eight inflammatory biomarkers measured in 1,269 older persons. The study sample is a subset of the Health, Aging, and Body Composition study.
The two components explained 56% of the total variance in the data (34%, component 1 and 22%, component 2). Five markers (tumor necrosis factor-alpha [TNF-α], sTNFRI, sTNFRII, interleukin [IL]-6sR, IL-2sR) loaded highest on the first component (TNF-α related), whereas three markers (C-reactive protein [CRP], IL-6, plasminogen activator inhibitor-1) loaded highest on the second component (CRP related). After adjusting for age, sex, race, site, sampling indicator, total lean and fat mass, physical activity, smoking, and anti-inflammatory drug use, knee strength and a physical performance battery score were inversely related to the TNF-α-related component, but not to the CRP-related component (knee strength: β^TNFα = −2.71, p = .002; β^CRP = −0.88, p = .325; physical performance battery score: β^TNFα = −0.05, p < .001; β^CRP = −0.02, p = .171). Both components were positively associated with 400-m walk time, inversely associated with grip strength, and not associated with 20-m walking speed.
At least two inflammatory components can be identified in an older population, and these components have inconsistent associations with different aspects of physical performance.
PMCID: PMC2800809  PMID: 19228783
Inflammation; Physical function; Aging; Principal component analysis
Sarcopenia, the involuntary loss of skeletal muscle with age, affects up to one-quarter of older adults. Evidence indicates a positive association between dietary protein intake and lean muscle mass and strength among older persons, but information on dietary protein’s effect on physical performance in older adults has received less attention.
Cross-sectional observational analysis of the relationship of dietary protein on body composition and physical performance.
Clinical research center.
387 healthy women aged 60 – 90 years (mean 72.7 ± 7.0 y).
Measures included body composition (fat-free mass, appendicular skeletal mass and fat mass) via dual x-ray absorptiometry (DXA), physical performance (Physical Performance Test [PPT] and Short Physical Performance Battery [SPPB]), handgrip strength, Physical Activity Scale in the Elderly (PASE), quality of life measure (SF-8), falls, fractures, nutrient and macromolecule intake (four-day food record). Independent samples t-tests determined mean differences between the above or below RDA protein groups.
Statistical Analysis
Analysis of covariance was used to control for body mass index (BMI) between groups when assessing physical performance, physical activity and health-related quality of life.
The subjects consumed an average of 72.2 g protein/day representing 1.1 g protein/kg body weight/day. Subjects were categorized as below the recommended daily allowance (RDA) for protein (defined as less than 0.8 g protein/kg) or at or above the RDA (equal to or higher than 0.8 g protein/kg). Ninety-seven subjects (25%) were in the low protein group, and 290 (75%) were in the higher protein group. Women in the higher protein group had lower body mass, including fat and lean mass, and fat-to-lean ratio than those in the lower-protein group (p <0.001). Composite scores of upper and lower extremity strength were impaired in the group with low protein intake; SPPB score was 9.9±1.9 compared to 10.6±1.6 in those with higher protein intake and PPT was 19.8± 2.9 compared to 20.9± 2.1 in the low and higher protein groups, respectively. The results were attenuated by correction for BMI, but remained significant. The physical component of the SF-8 was also lower in the low protein group but did not remain significant when controlling for BMI. No significant differences were found in hand grip strength or reported physical activity.
Healthy, older postmenopausal women consumed, on average, 1.1 g/kg/d protein, although 25% consumed less than the RDA. Those in the low protein group had higher body fat and fat-to-lean ratio than those who consumed the higher protein diet. Upper and lower extremity function was impaired in those who consumed a low protein diet compared to those with a higher protein intake. Protein intake should be considered when evaluating the multi-factorial loss of physical function in older women.
PMCID: PMC4433492  PMID: 24522467
Protein; body composition; physical performance; frailty
10.  Use of the Short Physical Performance Battery Score to Predict Loss of Ability to Walk 400 Meters: Analysis From the InCHIANTI Study 
Early detection of mobility limitations remains an important goal for preventing mobility disability. The purpose of this study was to examine the association between the Short Physical Performance Battery (SPPB) and the loss of ability to walk 400 m, an objectively assessed mobility outcome increasingly used in clinical trials.
The study sample consisted of 542 adults from the InCHIANTI study aged 65 and older, who completed the 400 m walk at baseline and had evaluations on the SPPB and 400 m walk at baseline and 3-year follow-up. Multiple logistic regression models were used to determine whether SPPB scores predict the loss of ability to walk 400 m at follow-up among persons able to walk 400 m at baseline.
The 3-year incidence of failing the 400 m walk was 15.5%. After adjusting for age, sex, education, body mass index, Mini-Mental State Examination, number of medical conditions, and 400 m walk gait speed at baseline, SPPB score was significantly associated with loss of ability to walk 400 m after 3 years. Participants with SPPB scores of 10 or lower at baseline had significantly higher odds of mobility disability at follow-up (odds ratio [OR] = 3.38, 95% confidence interval [CI]: 1.32–8.65) compared with those who scored 12, with a graded response across the range of SPPB scores (OR = 26.93, 95% CI: 7.51–96.50; OR = 7.67, 95% CI: 2.26–26.04; OR = 8.28, 95% CI: 3.32–20.67 for SPPB ≤ 7, SPPB 8, and SPPB 9, respectively).
The SPPB strongly predicts loss of ability to walk 400 m. Thus, using the SPPB to identify older persons at high risk of lower body functional limitations seems a valid means of recognizing individuals who would benefit most from preventive interventions.
PMCID: PMC2655026  PMID: 19182232
Mobility; 400 m walk; Incidence of disability; Functional limitation; Aging
11.  Association of C-reactive protein and muscle strength in the English Longitudinal Study of Ageing 
Age  2009;31(3):171-177.
Sarcopenia has been associated with systemic inflammation and a range of other biological risk factors. The purpose of this study was to assess the systemic inflammation–muscle strength relationship in a large representative community-based cohort of older adults, and to determine the independence of this association from other biological and psychosocial risk factors. Participants were 1,926 men and 2,260 women (aged 65.3 ± 9.0 years) from the English Longitudinal Study of Ageing, a study of community dwelling older adults. We assessed hand grip strength and lower body strength (time required to complete five chair stands). Biological measures included C-reactive protein (CRP), fibrinogen, cholesterol, haemoglobin, glycated haemoglobin, adiposity, and blood pressure. Approximately 33% of the sample demonstrated elevated concentrations (≥3 mg/L) of CRP. After adjustments for age, smoking, physical activity, education, inflammatory diseases, and all other biological factors, elevated CRP was associated with poorer hand grip strength and chair stand performance in women but only chair stand performance in men. Low haemoglobin levels were consistently associated with poorer performance on both tests in women and men. These results confirm an independent association between low grade systemic inflammation (as indexed by CRP) and muscle strength that appears to be more robust in women.
PMCID: PMC2734243  PMID: 19466582
Inflammation; Muscle strength; Sarcopenia; Community sample
12.  Total and Abdominal Adiposity Are Associated With Inflammation in Older Adults Using a Factor Analysis Approach 
Obesity-related increases in multiple inflammatory markers may contribute to the persistent subclinical inflammation common with advancing age. However, it is unclear if a specific combination of markers reflects the underlying inflammatory state. We used factor analysis to identify inflammatory factor(s) and examine their associations with adiposity in older adults at risk for disability.
Adiponectin, CRP, IL-1ra, IL-1sRII, IL-2sRα, IL-6, IL-6sR, IL-8, IL-15, sTNFRI, sTNFRII, and TNF-α were measured in 179 participants from the Lifestyle Interventions and Independence for Elders Pilot (Mean ± SD age 77 ± 4 years, 76% white, 70% women). Body mass index, waist circumference, and total fat mass were assessed by anthropometry and dual-energy x-ray absorptiometry.
IL-2sRα, sTNFRI, and sTNFRII loaded highest on the first factor (factor 1). CRP, IL-1ra, and IL-6 loaded highest on the second factor (factor 2). Factor 2, but not factor 1, was positively associated with 1-SD increments in waist circumference (β = 0.160 ± 0.057, p = .005), body mass index (β = 0.132 ± 0.053, p = .01), and total fat mass (β = 0.126 ± 0.053, p = .02) after adjusting for age, gender, race/ethnicity, site, smoking, anti-inflammatory medications, comorbidity index, health-related quality of life, and physical function. These associations remained significant after further adjustment for grip strength, but only waist circumference remained associated with inflammation after adjusting for total lean mass. There were no significant interactions between adiposity and muscle mass or strength for either factor.
Greater total and abdominal adiposity are associated with higher levels of an inflammatory factor related to CRP, IL-1ra, and IL-6 in older adults, which may provide a clinically useful measure of inflammation in this population.
PMCID: PMC3437966  PMID: 22451470
Aging; Adiposity; Inflammation; Muscle impairment; Factor analysis
13.  Health-Related Quality of Life in Older Adults at Risk for Disability 
The number of older adults living in the U.S. continues to increase, and recent research has begun to target interventions to older adults who have mobility limitations and are at risk for disability. The objective of this study is to describe and examine correlates of health-related quality of life in this population subgroup using baseline data from a larger intervention study.
The Lifestyle Interventions and Independence for Elders–Pilot study (LIFE–P) was a randomized, controlled trial that compared a physical activity intervention to a non-exercise educational intervention with 424 older adults at risk for disability. Baseline data (collected April–December 2004; analyzed in 2006) included demographics, medical history, the Quality of Well-Being Scale (QWB-SA), a timed 400 m walk, and the Short Physical Performance Battery (SPPB). Descriptive HRQOL data are presented. Hierarchical linear regression models were used to examine correlates of HRQOL.
The mean QWB-SA score for the sample was 0.630 on an interval scale ranging from 0.0 (death) to 1.0 (asymptomatic, optimal functioning). The mean of 0.630 is 0.070 lower than a comparison group of healthy older adults. The variables associated with lower HRQOL included white ethnicity, more comorbid conditions, slower 400-m walk times, and lower SPPB balance and chair stand scores.
Older adults who are at risk for disability had reduced HRQOL. Surprisingly, however, mobility was a stronger correlate of HRQOL than an index of comorbidity, suggesting that interventions addressing mobility limitations may provide significant health benefits to this population.
PMCID: PMC1995005  PMID: 17826582
14.  Effects of a 6-month multimodal training intervention on retention of functional fitness in older adults: A randomized-controlled cross-over design 
Older adults have the highest rates of disability, functional dependence and use of healthcare resources. Training interventions for older individuals are of special interest where regular physical activity (PA) has many health benefits. The main purpose of this study was to assess the immediate and long-term effects of a 6-month multimodal training intervention (MTI) on functional fitness in old adults.
For this study, 117 participants, 71 to 90 years old, were randomized in immediate intervention group and a control group (delayed intervention group). The intervention consisted of daily endurance and twice-a-week strength training. The method was based on a randomized-controlled cross-over design. Short Physical Performance Battery (SPPB), 8 foot up-and-go test, strength performance, six min walking test (6 MW), physical activity, BMI and quality of life were obtained at baseline, after a 6-month intervention- and control phase, again after 6-month crossover- and delayed intervention phase, and after anadditional 6-month follow-up.
After 6 months of MTI, the intervention group improved in physical performance compared with the control group via Short Physical Performance Battery (SPPB) score (mean diff = 0.6, 95 % CI: 0.1, 1.0) and 8-foot up-and-go test (mean diff = −1.0 s, 95 % CI: -1.5, -0.6), and in endurance performance via 6-minute walking test (6 MW) (mean diff = 44.2 meters, 95 % CI: 17.1, 71.2). In strength performance via knee extension the intervention group improved while control group declined (mean diff = 55.0 Newton, 95 % CI: 28.4, 81.7), and also in PA (mean diff = 125.9 cpm, 95 % CI: 96.0, 155.8). Long-term effects of MTI on the particpants was assesed by estimating the mean difference in the variables measured between time-point 1 and 4: SPPB (1.1 points, 95 % CI: 0.8, 1.4); 8-foot up-and-go (−0.9 s, 95 % CI: -1.2, -0.6); 6 MW (18.7 m, 95 % CI: 6.5, 31.0); knee extension (4.2 Newton, 95 % CI: -10.0, 18.3); hand grip (6.7 Newton, 95 % CI: -4.4, 17.8); PA (−4.0 cpm, 95 % CI: -33.9, 26.0); BMI (−0.6 kg/m2, 95 % CI: -0.9, -0.3) and Icelandic quality of life (0.3 points, 95 % CI: -0.7, 1.4).
Our results suggest that regular MTI can improve and prevent decline in functional fitness in older individuals, influence their lifestyle and positively affect their ability to stay independent, thus reducing the need for institutional care.
Trial registration
This study was approved by the National Bioethics Committee in Iceland, VSNb20080300114/03-1
PMCID: PMC3522556  PMID: 22963328
Physical activity; Functional fitness; SPPB; 6 MW; Strength; Cross-over design
15.  Education-related differences in physical performance after age 60: a cross-sectional study assessing variation by age, gender and occupation 
BMC Public Health  2013;13:641.
Having a low level of education has been associated with worse physical performance. However, it is unclear whether this association varies by age, gender or the occupational categories of manual and non-manual work. This study examined whether there are education-related differences across four dimensions of physical performance by age, gender or occupational class and to what extent chronic diseases and lifestyle-related factors may explain such differences.
Participants were a random sample of 3212 people, 60 years and older, both living in their own homes and in institutions, from the Swedish National Study on Aging and Care, in Kungsholmen, Stockholm. Trained nurses assessed physical performance in grip strength, walking speed, balance and chair stands, and gathered data on education, occupation and lifestyle-related factors, such as physical exercise, body mass index, smoking and alcohol consumption. Diagnoses of chronic diseases were made by the examining physician.
Censored normal regression analyses showed that persons with university education had better grip strength, balance, chair stand time and walking speed than people with elementary school education. The differences in balance and walking speed remained statistically significant (p < 0.05) after adjustment for chronic diseases and lifestyle. However, age-stratified analyses revealed that the differences were no longer statistically significant in advanced age (80+ years). Gender-stratified analyses revealed that women with university education had significantly better grip strength, balance and walking speed compared to women with elementary school education and men with university education had significantly better chair stands and walking speed compared to men with elementary school education in multivariate adjusted models. Further analyses stratified by gender and occupational class suggested that the education-related difference in grip strength was only evident among female manual workers, while the difference in balance and walking speed was only evident among female and male non-manual workers, respectively.
Higher education was associated with better lower extremity performance in people aged 60 to 80, but not in advanced age (80+ years). Our results indicate that higher education is associated with better grip strength among female manual workers and with better balance and walking speed among female and male non-manual workers, respectively.
PMCID: PMC3733740  PMID: 23842209
Educational status; Aging; Chronic diseases; Muscle strength; Walking; Postural balance
16.  Lifetime occupation and physical function: a prospective cohort study on persons aged 80 years and older living in a community 
Several studies have reported predictors for loss of mobility and impairments of physical performance among frail elderly people.
To evaluate the relationship between lifetime occupation and physical function in persons aged 80 years or older.
Data are from baseline evaluation of 364 subjects enrolled in the ilSIRENTE study (a prospective cohort study performed in a mountain community in Central Italy). Physical performance was assessed using the physical performance battery score, which is based on three timed tests: 4‐metre walking speed, balance, and chair stand tests. Muscle strength was measured by hand grip strength. Lifetime occupation was categorised as manual or non‐manual work.
Mean age of participants was 85.9 (SD 4.9) years. Of the total sample, 273 subjects (75%) had a history of manual work and 91 subjects (25%) a history of non‐manual work. Manual workers had significant lower grip strength and physical performance battery score (indicating worse performance) than non‐manual workers. After adjustment for potential confounders (including age, gender, education, depression, cognitive performance scale score, physical activity, number of diseases, hearing impairment, history of alcohol abuse, smoking habit, and haemoglobin level), manual workers had significantly worse physical function (hand grip strength: non‐manual workers 32.5 kg, SE 1.4, manual workers 28.2 kg, SE 0.8; physical performance battery score: non‐manual workers 7.1, SE 0.4, manual workers 6.1, SE 0.2).
A history of manual work, especially when associated with high physical stress, is independently associated with low physical function and muscle strength in older persons.
PMCID: PMC2092516  PMID: 16782827
lifetime occupation; physical performance; aging;  ilSIRENTE study
17.  Lifetime occupation and physical function: a prospective cohort study on persons aged 80 years and older living in a community 
Several studies have reported predictors for loss of mobility and impairments of physical performance among frail elderly people.
To evaluate the relationship between lifetime occupation and physical function in persons aged 80 years or older.
Data are from baseline evaluation of 364 subjects enrolled in the ilSIRENTE study (a prospective cohort study performed in a mountain community in Central Italy). Physical performance was assessed using the physical performance battery score, which is based on three timed tests: 4-metre walking speed, balance, and chair stand tests. Muscle strength was measured by hand grip strength. Lifetime occupation was categorised as manual or non-manual work.
Mean age of participants was 85.9 (SD 4.9) years. Of the total sample, 273 subjects (75%) had a history of manual work and 91 subjects (25%) a history of non-manual work. Manual workers had significant lower grip strength and physical performance battery score (indicating worse performance) than non-manual workers. After adjustment for potential confounders (including age, gender, education, depression, cognitive performance scale score, physical activity, number of diseases, hearing impairment, history of alcohol abuse, smoking habit, and haemoglobin level), manual workers had significantly worse physical function (hand grip strength: non-manual workers 32.5 kg, SE 1.4, manual workers 28.2 kg, SE 0.8; physical performance battery score: non-manual workers 7.1, SE 0.4, manual workers 6.1, SE 0.2).
A history of manual work, especially when associated with high physical stress, is independently associated with low physical function and muscle strength in older persons.
PMCID: PMC2092516  PMID: 16782827
18.  Association between physiological falls risk and physical performance tests among community-dwelling older adults 
Clinical Interventions in Aging  2015;10:1319-1326.
Physical performance and balance declines with aging and may lead to increased risk of falls. Physical performance tests may be useful for initial fall-risk screening test among community-dwelling older adults. Physiological profile assessment (PPA), a composite falls risk assessment tool is reported to have 75% accuracy to screen for physiological falls risk. PPA correlates with Timed Up and Go (TUG) test. However, the association between many other commonly used physical performance tests and PPA is not known. The aim of the present study was to examine the association between physiological falls risk measured using PPA and a battery of physical performance tests.
One hundred and forty older adults from a senior citizens club in Kuala Lumpur, Malaysia (94 females, 46 males), aged 60 years and above (65.77±4.61), participated in this cross-sectional study. Participants were screened for falls risk using PPA. A battery of physical performance tests that include ten-step test (TST), short physical performance battery (SPPB), functional reach test (FRT), static balance test (SBT), TUG, dominant hand-grip strength (DHGS), and gait speed test (GST) were also performed. Spearman’s rank correlation and binomial logistic regression were performed to examine the significantly associated independent variables (physical performance tests) with falls risk (dependent variable).
Approximately 13% older adults were at high risk of falls categorized using PPA. Significant differences (P<0.05) were demonstrated for age, TST, SPPB, FRT, SBT, TUG between high and low falls risk group. A significant (P<0.01) weak correlation was found between PPA and TST (r=0.25), TUG (r=0.27), SBT (r=0.23), SPPB (r=−0.33), and FRT (r=−0.23). Binary logistic regression results demonstrated that SBT measuring postural sways objectively using a balance board was the only significant predictor of physiological falls risk (P<0.05, odds ratio of 2.12).
The reference values of physical performance tests in our study may be used as a guide for initial falls screening to categorize high and low physiological falls risk among community-dwelling older adults. A more comprehensive assessment of falls risk can be performed thereafter for more specific intervention of underlying impairments.
PMCID: PMC4541555  PMID: 26316727
balance; postural sways; agility; mobility; strength; gait speed
19.  Body Mass Index, Muscle Strength and Physical Performance in Older Adults from Eight Cohort Studies: The HALCyon Programme 
PLoS ONE  2013;8(2):e56483.
To investigate the associations of body mass index (BMI) and grip strength with objective measures of physical performance (chair rise time, walking speed and balance) including an assessment of sex differences and non-linearity.
Cross-sectional data from eight UK cohort studies (total N = 16 444) participating in the Healthy Ageing across the Life Course (HALCyon) research programme, ranging in age from 50 to 90+ years at the time of physical capability assessment, were used. Regression models were fitted within each study and meta-analysis methods used to pool regression coefficients across studies and to assess the extent of heterogeneity between studies.
Higher BMI was associated with poorer performance on chair rise (N = 10 773), walking speed (N = 9 761) and standing balance (N = 13 921) tests. Higher BMI was associated with stronger grip strength in men only. Stronger grip strength was associated with better performance on all tests with a tendency for the associations to be stronger in women than men; for example, walking speed was higher by 0.43 cm/s (0.14, 0.71) more per kg in women than men. Both BMI and grip strength remained independently related with performance after mutual adjustment, but there was no evidence of effect modification. Both BMI and grip strength exhibited non-linear relations with performance; those in the lowest fifth of grip strength and highest fifth of BMI having particularly poor performance. Findings were similar when waist circumference was examined in place of BMI.
Older men and women with weak muscle strength and high BMI have considerably poorer performance than others and associations were observed even in the youngest cohort (age 53). Although causality cannot be inferred from observational cross-sectional studies, our findings suggest the likely benefit of early assessment and interventions to reduce fat mass and improve muscle strength in the prevention of future functional limitations.
PMCID: PMC3577921  PMID: 23437142
20.  Lower Extremity Muscle Mass Predicts Functional Performance in Mobility-Limited Elders 
This study examined the influence of lower extremity body composition and muscle strength on the severity of mobility-disability in community-dwelling older adults.
Fifty-seven older males and females (age 74.2 ± 7 yrs; BMI 28.9 ± 6 kg/m2) underwent an objective assessment of lower extremity functional performance, the Short Physical Performance Battery test (SPPB). Participants were subsequently classified as having moderate (SPPB score > 7: n = 38) or severe mobility impairments (SPPB score ≤7: n = 19). Body composition was assessed using dual-energy X-ray absorptiometry and provided measures of bone mineral density (BMD), total leg lean mass (TLM) and total body fat. Maximal hip extensor muscle strength was estimated using the bilateral leg press exercise. Multiple logistic regression analysis was utilized to identify the significant independent variables that predicted the level of mobility-disability.
TLM was a strong independent predictor of the level of functional impairment, after accounting for chronic medical conditions, BMD, body fat, body weight and habitual physical activity. In a separate predictive model, reduced muscle strength was also a significant predictor of severe functional impairment. The severity of mobility-disability was not influenced by gender (p = 0.71). A strong association was elicited between TLM and muscle strength (r = 0.78, p < 0.01).
These data suggest that lower extremity muscle mass is an important determinant of physical performance among functionally-limited elders. Such findings may have important implications for the design of suitable strategies to maintain independence in older adults with compromised physical functioning. Additional studies are warranted to assess the efficacy of lifestyle, exercise or therapeutic interventions for increasing lean body mass in this population.
PMCID: PMC2544628  PMID: 18615232
Aging; Sarcopenia; Mobility; Muscle Mass; Strength
21.  Effects of a weight loss plus exercise program on physical function in overweight, older women: a randomized controlled trial 
Obesity and a sedentary lifestyle are associated with physical impairments and biologic changes in older adults. Weight loss combined with exercise may reduce inflammation and improve physical functioning in overweight, sedentary, older adults. This study tested whether a weight loss program combined with moderate exercise could improve physical function in obese, older adult women.
Participants (N = 34) were generally healthy, obese, older adult women (age range 55–79 years) with mild to moderate physical impairments (ie, functional limitations). Participants were randomly assigned to one of two groups for 24 weeks: (i) weight loss plus exercise (WL+E; n = 17; mean age = 63.7 years [4.5]) or (ii) educational control (n = 17; mean age = 63.7 [6.7]). In the WL+E group, participants attended a group-based weight management session plus three supervised exercise sessions within their community each week. During exercise sessions, participants engaged in brisk walking and lower-body resistance training of moderate intensity. Participants in the educational control group attended monthly health education lectures on topics relevant to older adults. Outcomes were: (i) body weight, (ii) walking speed (assessed by 400-meter walk test), (iii) the Short Physical Performance Battery (SPPB), and (iv) knee extension isokinetic strength.
Participants randomized to the WL+E group lost significantly more weight than participants in the educational control group (5.95 [0.992] vs 0.23 [0.99] kg; P < 0.01). Additionally, the walking speed of participants in the WL+E group significantly increased compared with that of the control group (reduction in time on the 400-meter walk test = 44 seconds; P < 0.05). Scores on the SPPB improved in both the intervention and educational control groups from pre- to post-test (P < 0.05), with significant differences between groups (P = 0.02). Knee extension strength was maintained in both groups.
Our findings suggest that a lifestyle-based weight loss program consisting of moderate caloric restriction plus moderate exercise can produce significant weight loss and improve physical function while maintaining muscle strength in obese, older adult women with mild to moderate physical impairments.
PMCID: PMC3131984  PMID: 21753869
obesity; weight loss; physical function; oxidative stress; inflammation; walking speed
22.  Angiotensin-Converting Enzyme Inhibitor Use by Older Adults Is Associated with Greater Functional Responses to Exercise 
To assess the association between angiotensin converting enzyme inhibitors (ACEis) and improvements in the physical function of older adults in response to chronic exercise training.
Secondary analysis of the Lifestyle Interventions and Independence for Elders Pilot (LIFE-P) study, a multisite randomized clinical trial to evaluate the effects of chronic exercise on the physical function of older adults at risk for mobility disability.
Four academic research centers within the United States.
Four hundred twenty-four individuals aged 70 to 89 with mild to moderate functional impairments categorized for this analysis as ACEi users, users of other antihypertensive drugs, or antihypertensive nonusers.
A 12-month intervention of structured physical activity (PA) or health education promoting successful aging (SA).
Change in walking speed during a 400-m test and performance on a battery of short-duration mobility tasks (Short Physical Performance Battery (SPPB)).
Physical activity significantly improved the adjusted walking speed of ACEi users (P < .001) but did not of nonusers. PA improved the adjusted SPPB score of ACEi users (P < .001) and of persons who used other antihypertensive drugs (P = .005) but not of antihypertensive nonusers (P = .91). The percentage of ACEi users deriving clinically significant benefit from exercise training for walking speed (30%) and SPPB score (48%) was dramatically higher than for nonusers (14% and 12%, respectively).
For older adults at risk for disability, exercise-derived improvements in physical function were greater for ACEi users than users of other antihypertensive drugs and antihypertensive nonusers.
PMCID: PMC3625953  PMID: 22726232
aging; exercise; physical function; LIFE Study; ACE inhibitors
Background and Aims
Falls are a common cause of morbidity and mortality in the elderly, but the consequences of falls on physical function measures are still unclear. The present study explores the association between history of falls and physical function measures in older persons.
Data are from baseline evaluation of the ilSIRENTE study. Physical performance was assessed using the Short Physical Performance Battery (SPPB) and the 4-m walking test. Muscle strength was measured by hand grip strength. Functional status was assessed using the Basic and Instrumental Activities of Daily Living (ADLs and IADLs, respectively) scales. Self reported history of falls occurred during the previous 90 days was recorded. Analyses of covariance and linear regression models were performed to evaluate the relationship between history of falls and physical function measures.
Mean age of participants (n=364) was 85.9 (SD=4.9) years. Fifty participants (15.9%) reported at least one fall event in the previous 90 days. Participants with history of falls had significantly lower adjusted means for the 4-m walking test (0.382 m/s) and the SPPB score (5.602) compared to non fallers (0.498 m/s and 6.780, respectively, all p< 0.05). No statistically significant association of hand grip strength, ADLs and IADLs scales with history of falls was reported after adjustment. Physical activity was the strongest confounder of the association between history of falls and physical function. Physically active participants had a significantly higher physical function compared to sedentary subjects, regardless of history of falls.
Physical performance measures, walking speed and SPPB in particular, are negatively associated with history of falls.
PMCID: PMC4369671  PMID: 18594191
24.  Predictive Value of the Short Physical Performance Battery Following Hospitalization in Older Patients 
Hospitalization represents a stressful and potentially hazardous event for older persons. We evaluated the value of the Short Physical Performance Battery (SPPB) in predicting rates of functional decline, rehospitalization, and death in older acutely ill patients in the year after discharge from the hospital.
Prospective cohort study of 87 patients aged 65 years and older who were able to walk and with a Mini-Mental State Examination score ≥18 and admitted to the hospital with a clinical diagnosis of congestive heart failure, pneumonia, chronic obstructive pulmonary disease, or minor stroke. Patients were evaluated with the SPPB at hospital admission, were reevaluated the day of hospital discharge, and 1 month later. Subsequently, they were followed every 3 months by telephone interviews to ascertain functional decline, new hospitalizations, and vital status.
After adjustment for potential confounders, including self-report activity of daily living and comorbidity, the SPPB score at discharge was inversely correlated with the rate of decline in activity of daily living performance over the follow-up (p < .05). In a multivariable discrete-time survival analysis, patients with poor SPPB scores at hospital discharge (0–4) had a greater risk of rehospitalization or death (odds ratio: 5.38, 95% confidence interval: 1.82–15.9) compared with those with better SPPB scores (8–12). Patients with early decline in SPPB score after discharge also had steeper increase in activity of daily living difficulty and higher risk of rehospitalization or death over the next year.
In older acutely ill patients who have been hospitalized, the SPPB provides important prognostic information. Lower extremity performance-based functional assessment might identify older patients at high risk of poor outcomes after hospital discharge.
PMCID: PMC3011958  PMID: 20861145
SPPB; Hospitalization; Disability; Mortality; Prognosis
25.  Association Between Short Physical Performance Battery and Falls in Older People: The Progetto Veneto Anziani Study 
Rejuvenation Research  2014;17(3):276-284.
It is known that weakness in the lower limbs is associated with recurrent falls in old people. Among the tests routinely used to assess lower extremity strength, the Short Physical Performance Battery (SPPB) is one of those used most often, but its relationship with recurrent falls is poorly investigated. We aimed to determine if SPPB scores are related to recurrent falling in a sample of 2710 older-aged people, and to ascertain which test in the SPPB is most strongly associated with a higher rate of falls. In this cross-sectional study, we demonstrated that participants scoring 0–6 in the SPPB were more likely to be recurrent fallers than those scoring 10–12 (odds ratio [OR]=3.46, 95% confidence interval [CI] 2.04–5.88 in women; OR=3.82, 95% CI 1.77– 8.52, in men). SPPB scores of 7–9 were only associated with women being more likely to be recurrent fallers (OR=2.03, 95% CI 1.28–3.22). When the SPPB items were analyzed separately, even a lower score in gait speed for women was significantly associated with the presence of recurrent falls (OR=2.11; 95% CI 1.04–4.30), whereas in men only a significant increase in the time taken to complete the five timed chair stands test was associated with a higher rate of falls (OR=2.75; 95% CI 1.21–6.23). In conclusion, our study demonstrated that SPPB scores ≤6 are associated with a higher fall rate in old people of both genders; in females, even an SPPB score between 7 and 9 identifies subjects at a higher likelihood of being recurrent fallers. Among the single items of the SPPB, the most strongly associated with falls were gait speed in women and the five timed chair stands test in men.
PMCID: PMC4062103  PMID: 24387140

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