New report on mobility has experts moving toward consensus on care as we age

Mobility can be defined as the ability to move or be moved freely and easily. In older adults, mobility impairments are common and associated with risk for additional loss of function. Mobility loss is particularly common in these individuals during acute illness and hospitalization, and it is associated with poor outcomes, including loss of muscle mass and strength, long hospital stays, falls, declines in activities of daily living, decline in community mobility and social participation, and nursing home placement. 

Experts at the American Geriatrics Society (AGS) today unveiled a list of recommendations to help health systems prioritize a vital function for us all as we age: mobility. Mobility refers to our ability to move freely and easily (on our own or with assistance). 

08 oct 2018--Published today in the Journal of the American Geriatrics Society (JAGS), the AGS white paper focuses on assessing mobility for hospitalized older adults, offering a roadmap for shifting health care's focus away from negative markers of mobility loss and toward a deeper appreciation of ways mobility can be proactively assessed—and often preserved—to promote high-quality, person-centered care.
"Being able to maintain mobility is a top priority for many older adults facing a hospital stay," said Heidi Wald, MD, MSPH, Vice President for Clinical Performance and Interim Vice President for Quality and Safety at SCL Health in Colorado and one of the lead authors on the AGS white paper. "So it's surprising that mobility still isn't a widely recognized outcome when we look at quality of care. With this new summary of research and recommendations, we hope will can move our health system toward assessing mobility more appropriately and ideally preventing mobility loss as we age."
Most people already lose muscle strength and mass as they age, for example, but hospitalized older adults can lose up to 10 percent of their muscle strength per week of bed rest during a hospital stay. More than a third of hospital patients over age 70 are discharged with a major disability that was not present before their admission, with many also experiencing increased hospital stays and poorer abilities to perform the activities of daily living due in part to mobility loss.
Yet while the loss of mobility is common as we age, AGS experts note that nothing is commonplace about the impact of this trend on overall well-being.
"Mobility loss is critical in what we call the 'cascade' to dependence—a slippery slope that can start with small declines in movement but can ultimately lead to falls, further hospitalizations, and a general loss of independence," Dr. Wald observed. "Thankfully, there are ways we can prevent and perhaps even reverse that cascade—but that means doing more to assess and address mobility in a coordinated fashion."
In their new white paper, representatives from the AGS Quality and Performance Measurement Committee reviewed existing research on mobility loss during hospitalization, including the implications of low mobility, the current state of mobility assessment, and ways we can use new and existing tools to promote routine evaluation of how well mobility is preserved following hospital stays. While standardized programs across all hospitals may be difficult to develop, the AGS expert panel arrived at seven recommendations they believe leverage the best existing science in effective ways for the whole of our national health system.

Recommendation 1: Promote mobility assessment in acute care.

Regulations put in place by agencies like the Centers for Medicare and Medicaid Services (CMS) often shape how care will be put into practice. These agencies can promote greater attention to mobility by incentivizing the use of validated assessments that integrate with existing tests to minimize the burden on providers.

Recommendation 2: Advocate for more research funding.

Federally funded groups like the National Institutes of Health and the Agency for Healthcare Research and Quality also can shape the future of improved mobility by prioritizing research to translate mobility assessment and quality measurement into intervention programs that can protect and promote our ability to continue moving freely as we age—and especially as we face recovery following a hospital stay.

Recommendation 3: Develop consensus on standard methods to assess mobility.

Existing programs to assess and promote mobility vary greatly—and standardizing them across hospitals is difficult and perhaps even unnecessary. Stakeholders can help improve care, however, by promoting broader consensus around specific assessments that are validated; appropriate for acute-care setting like hospitals; and capable of providing health professionals, older people, and caregivers with meaningful, actionable data.

Recommendation 4: Minimize the burden of mobility measurement.

Hospitals and health professionals alike already balance a range of measures and metrics to assess the care they provide. To promote mobility more appropriate, stakeholders will need to focus on optimizing workflows and documentation to minimize redundancy while also ensuring mobility measures become a priority.

Recommendation 5: Evaluate the feasibility of a mobility quality measure.

Organizations like CMS also shape health priorities in determining which "quality measures"—specific aspects of care evaluated by regulators to assess safety and care value—are used when reviewing health outcomes. By developing a specific quality measure for mobility, CMS could incentivize hospitals, staff, and providers to prevent loss of mobility even more proactively.

Recommendation 6: Reframe the current regulatory focus on falls in acute care to a focus on safe mobility.

The current focus on preventing falls at all costs has led to unintended consequences that may actually impede efforts to protect and preserve mobility. AGS experts recommend reconsidering falls as an indicator of quality care in the absence of a corresponding measure to assess mobility more fully.

Recommendation 7: Develop resources for acute-care providers.

Organizations like the AGS and its stakeholders have also been encouraged to create new tools, processes, and strategies to assist healthcare professionals and hospitals with implementing mobility assessments and interventions. Putting together such resources will represent a critical step forward for the field.
The AGS white paper, "The Case for Mobility Assessment in Hospitalized Older Adults" is available for free from JAGS at https://onlinelibrary.wiley.com/doi/full/10.1111/jgs.15595.

AGS ACTION POINTS

• Though being able to maintain mobility is a top priority for many older adults facing a hospital stay, mobility still is not a widely recognized outcome when we look at quality of care.
• Specific strategies identified by AGS experts for fostering greater attention to mobility assessment include (1) promoting its assessment in hospitals and health systems, (2) advocating for more mobility research funding, (3) developing consensus on mobility assessment standards, (4), working to minimize the burden of mobility assessment, (5) evaluating the feasibility of a mobility quality measure, (6) reframing the current regulatory focus on falls versus mobility, and (7) developing mobility-assessment resources to help healthcare providers.

More information: Heidi L. Wald et al, The Case for Mobility Assessment in Hospitalized Older Adults: American Geriatrics Society White Paper Executive Summary, Journal of the American Geriatrics Society (2018). DOI: 10.1111/jgs.15595


Provided by American Geriatrics Society

Study proves physical activity helps maintain mobility in older adults

Credit: Peter Griffin/public domain

It's something we've all heard for years: Exercise can help keep older adults healthy. But now a study, the first of its kind to look at frail, older adults, proves that physical activity can help these people maintain their mobility and dodge physical disability.

A new University of Florida study shows daily moderate physical activity may mean the difference between seniors being able to keep up everyday activities or becoming housebound. In fact, moderate physical activity helped aging adults maintain their ability to walk at a rate 18 percent higher than older adults who did not exercise. "The very purpose of the study is to provide definitive evidence that physical activity can truly improve the independence of older adults," said principal investigator Marco Pahor, Ph.D., director of the UF's Institute on Aging.

What's more, moderate physical activity not only helped older adults maintain mobility but also helped prevent the occurrence of long-term mobility loss. Co-principal investigator Jack Guralnik, Ph.D., a professor of epidemiology and public health at the University of Maryland School of Medicine, said there was a 28 percent reduction in people permanently losing the ability to walk easily.

"The fact that we had an even bigger impact on persistent disability is very good," said Guralnik, who also holds a faculty position at UF. "It implies that a greater percentage of the adults who had physical activity intervention recovered when they did develop mobility disability."

The results will be published in the May issue of the Journal of the American Medical Association and will be presented at 1 p.m. Tuesday (May 27) at the annual meeting of the American College of Sports Medicine in Orlando.

Researchers showed that prescribed daily physical activity can prevent older adults' loss of mobility, defined in the study as the ability to walk 400 meters, or about a quarter of a mile. Although 400 meters might sound like an arbitrary number, it's an important figure for older adults, researchers said.

"Four hundred meters is once around the track, or from the parking lot to the store, or two or three blocks around your neighborhood," Guralnik said. "It's an important distance in maintaining an independent life." Called the Lifestyle Interventions and Independence for Elders, or LIFE, study, the study took place across eight field centers. There were two Florida field center recruitment sites at the University of Florida and Jacksonville Brooks Rehabilitation as well as field centers at Northwestern University, Pennington Biomedical Research Center, the University of Pittsburgh, Stanford University, Tufts University, Wake Forest School of Medicine and Yale University.

The researchers recruited 1,635 sedentary men and women ages 70 to 89 for the study. The participants could walk a quarter mile within 15 minutes but were at risk of losing that ability. Low physical performance can be a predictor of early death and higher hospitalization and institutionalization rates, and patients with low physical performance are not often recruited to large studies, Pahor said.

"These are people who are patients we see every day. This is why this study is so important: It includes a population that is typically understudied," Pahor said.

The participants were randomly separated into two groups and followed for an average of 2.6 years. The first group of 818 walked 150 minutes per week and did strength, flexibility and balance training. They were monitored by two visits to field centers per week. The second group of 817 attended health education classes and performed stretching exercises. This phase of the study occurred between February 2010 and December 2013.

Staff members assessed study participants every six months, checking their ability to walk, their body weight, blood pressure and pulse rate, among other measurements. The staff was not told which participants were assigned to physical activity or to the education classes.

The study did turn up one unanticipated result: The number of people reporting hospitalizations in the physical activity group was slightly higher than in the education group, though the number was not statistically significant. The researchers think this is in part because the physical activity group had more frequent contact with research staff, possibly resulting in a higher reporting of hospitalizations. The physical activity could also have triggered underlying heart trouble and other health problems. Researchers plan to study this occurrence more closely, Pahor said.

"It's quite a vulnerable and high-risk population," Pahor said. "Both age and poor health were factors. We selected people who had low physical performance, which is a strong predictor for future morbidity, hospitalization, institutionalization and mortality."

Wendy Kohrt, Ph.D., professor of medicine in the division of geriatric medicine at the University of Colorado, helped review the scientific merit of the study before the launch of the main LIFE trial. She said the information produced by this study fills gaps in researchers' knowledge of the types of people enrolled in the study.

"As an exercise scientist, I believe this type of research is absolutely critical to establish scientific evidence on which to make recommendations for how lifestyle can beneficially influence health status," Kohrt said. "There is a general belief among the public and the scientific and medical communities that we know exercise is good for you, so why do we need to do more research in this area? However, we still do not know whether certain types or doses of exercise are better than others, particularly for specific health conditions or diseases. The LIFE trial demonstrated that a modest increase in physical activity has the potential to help older adults maintain functional independence."

Pahor and Guralnik said there is still a vast amount of data to unpack from the study, including looking at the effects of physical activity on the participants' emotional well-being. The research team also plans to determine how physical activity impacted the participants' physiological, social and biological factors.

Weight loss plus walking essential for older, obese adults

Walking more and losing weight can improve mobility as much as 20 percent in older, obese adults with poor cardiovascular health, according to a new Wake Forest University study.

25 jan 2010--The results from the five-year study of 288 participants appear online Jan. 24 in the Archives of Internal Medicine.

The combination of weight loss and physical activity is what works best. These findings run counter to the commonly held belief that it is unhealthy for older adults to lose weight.

"To improve mobility, physical activity has to be coupled with weight loss," said Jack Rejeski, Thurman D. Kitchin Professor of Health and Exercise Science. "This is one of the first large studies to show that weight loss improves the functional health of older people with cardiovascular disease."

The study addresses what to do to help seniors with poor mobility, but it also proves existing community agencies can be used effectively to get seniors the help they need.

"With 60 percent of adults over age 65 walking less than one mile per week and a rapidly growing population of older adults, the need for cost-effective community-based intervention programs to improve the mobility of seniors is critical," said Rejeski, principal investigator for the Cooperative Lifestyle Intervention Program (CLIP). Key co-investigators included Dr. David C. Goff and Walter T. Ambrosius from Wake Forest University School of Medicine, Peter Brubaker, professor of health and exercise science at Wake Forest, Lucille Bearon and Jacquelyn McClelland from North Carolina State University, and Michael Perri from the University of Florida.

"Community-based preventative programs are extremely important," Rejeski said.

The researchers partnered with the North Carolina Cooperative Extension and trained health care professionals at centers in three counties (Davidson, Forsyth and Guilford) to lead the programs along with an intervention team from Wake Forest. The participants, ranging in age from 60 to 79, were tracked over an 18-month period. The study divided participants into three groups: a control group who received education on successful aging, a physical activity only group, and a physical activity and weight loss group.

The physical activity group did well, but the most dramatic effect was found in the participants who combined an increase in physical activity with weight loss.

On average, they improved their mobility by 5 percent as measured by the time it took them to walk 400 meters. Those with the most limited mobility improved by as much as 20 percent.

The 400-meter walk is a widely used measure of mobility disability in older adults because for those who cannot walk this distance the likelihood of losing their independence increases dramatically.

Rejeski uses this analogy for the loss of mobility in seniors who often don't realize its seriousness. "It is like being in a canoe paddling down a river and being completely unaware that a waterfall is only a short distance away. Once your canoe starts down the waterfall of disability, the consequences are severe."

The waterfall is the cascade of adverse outcomes including hospitalizations, worsening disability, institutionalization, and death that are more likely when seniors lose the basic ability to get around. Seniors with limited mobility require significantly more high-cost medical care.

"Clearly the ability to walk without assistance is a critical factor in an older person's capacity to function independently in the community," he said. "The next step is to develop a model that can be replicated at similar sites across the state and the country and we look forward to working with our colleagues from North Carolina to achieve this goal."

Provided by Wake Forest University

Extra Pounds in Mid-Life Affect Later Mobility

11 april 2009-- Seniors who were overweight or obese earlier in life are at increased risk for physical disabilities, even if they've shed the excess weight they had when they were younger, says a new U.S. study.

"In both men and women, being overweight or obese put them at greater risk of developing mobility limitations in old age, and the longer they had been overweight or obese, the greater the risk," lead investigator Denise Houston, an expert on aging and nutrition and an assistant professor of gerontology at the School of Medicine at Wake Forest University Baptist Medical Center, said in a center news release.

"We also found that, if you were of normal weight in old age but had previously been overweight or obese, you were at greater risk for mobility limitations," she added.

Houston noted that weight loss later in life is usually caused by an underlying chronic condition.

The study included 2,845 participants who were an average of 74 years old when they were enrolled. They had no mobility problems at the start of the study. During seven years of follow-up, women who were overweight or obese (body mass index of 25 or greater) from their mid-20s to their 70s were nearly three times more likely to develop mobility problems than women who were normal weight throughout their lives. Overweight or obese men were 1.6 times more likely to develop mobility problems.

The researchers also found that women who were obese (BMI of 30 or greater) at age 50, but not in their 70s, were 2.7 times more likely to develop mobility limitations than women who weren't obese throughout their lives. Men with a similar weight history were 1.8 times more likely to develop mobility problems.

The study is in the April 15 issue of the American Journal of Epidemiology.

Excess weight can put stress on joints, make exercise difficult, and lead to chronic conditions such as diabetes, arthritis and heart disease -- all of which are directly related to the development of mobility problems, Houston said.